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Chain of Custody and Analytical Request Record <br />PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of 1 <br />Company Name: Cotter Corporation Project Name: Schwartrwalder Water Monitoring Program - Discharge <br />Tracking No. 3692013 00179957 DATE: _12109110 SSTF: S25510 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick <br />PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 213 Bob Tennant <br />Invoice Address: Invoice Contact: Kristy Usnick Purchase Order #: ELI Quote <br />PO Box 1750 Tel: 1-719-275-7413 ext. 213 <br />Canon City, CO 81215-1750 Fax: 1-719-275-1669 <br /> Notify ELI prior to Recei <br />t Tem <br /> <br />l p <br />p <br />Report Required For: POTW/WWVPP ? RUSH samp <br />e 3\ k-,;L o C <br />Other <br />a submittal for <br />h <br />dditi <br />l <br />CooleF iD(s <br />Special Report Formats - ELI must be notified .. o arges <br />a <br />ona <br />c <br />, <br />prior to sample submittal for the following: m q? o t and scheduling <br />Custody <br />NELAC ? A2LA ? Level IV ? ay 2 a Comments: <br />Other <br />EDD/EDT ? Format E3 <br />2 <br />a m <br />_ o <br />E S&A Schedule Code : <br />Intact <br /> z <br />` o <br />a Z <br />a ~ <br />€ DIS CODE #2 <br />x Y/ N <br />nature <br />Si <br />SAMPLE ?a N <br />+ <br />+ z 0 Frequency: -1 g <br />Y / N <br />IDENTIFICATION Collection Collection a' J <br />Match LAB ID <br />(Name, Location, Date Time 19 N m <br />F Y/N <br />Interval, etc MATRIX <br />I DIS-001A--A 12/07/10 Shrsite Water ® ? ? ? ? ? ? ? ? ? 0 ? <br />2 DIS-001A---B 12/08/10 8hr <br />composite water ® ? ? ? ? ? ? ? ? ? ® ? <br /> _ <br />3 DIS-001A--C 12/09110 8hr water 01 0 ? ? ? ? ? ? ? ? ® ? <br /> com site <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />o ? ? ? ? ? ? ? ? ? ? ? ? <br />6 ? ? ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? l20 <br />B ? ? ? ? ? ? ? ? ? ? ? ? <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />,o ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />stod <br />C Relinquished by: Bob Tennant Datefrime: 12/09110 <br />Shipped by: <br />Receive by: Date/Time: \2 .ko •? <br />u <br />y 17:30 <br />Record <br />be <br />MUST <br />Relinquished by: Datefl-ime: <br />Shipped by: <br />Received by: Dateffime: \Z: I <br />? <br /> <br />Signed <br />Sample Disposal: Return to Client 11 Lab Disposal ® LABORATORY USE <br />ONLY <br />Sample Type # of fractions