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CD <br />N <br />O <br />N <br />W <br />]ni <br />kn?- GY <br />Chain of Custody and Analytical Request Record reverse side. Page 1 of 1 <br />PLEASE PRINT; provide as much information as possible. Refer to corresponding notes Company Name: Cotter Corporation <br />Tracking No. 3692013_00179995 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215-1750 <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215-1750 <br />Report Required For: POTWNVWTP ? <br />Other <br />Special Report Formats - ELI must be notified <br />prior to sample submittal for the following: <br />NELAC 2mi Level IV ? <br />Other <br />EDDIEDT ? Format <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval etc <br />1 DIS-001A <br />Collection collection <br />Date Time <br />12/20110 I 8h^ <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />a <br />9 <br />10 <br />Relinquished by: Bob Tennant <br />custody 16:30 <br />Record elinquished by: <br />R <br />MUST be <br />Signed Sample Disposal: <br />Project Name: Schwartzwaider W <br />DATE: 12120110 - SSTF: <br />Contact Name: Kristy Usnick <br />Voice: 1-719-275-7413 ext. 213 <br />Invoice Contact: Kristy Usnick <br />Tel: 1-719-275-7413 ext. 213 <br />Fax-, 1-719-275-1669 <br />ng program - Discharge <br />Sampker Name if other than Contact: <br />1-303-642-3893 Schwartzwalder <br />Bob Tennant 1719-371-3009 <br />Purchase Order #: ELI Quote #: <br />Notify ELI prior to <br />RUSH sample <br /> <br />a submittal for <br />F additional charges Coo r D(s) <br /> t and schedulin d <br />al <br />t <br />0 '1 nts: y <br />o <br />Cus <br />! <br /> Comme Y <br />d <br />a cc <br />E e <br />S&A Schedule Code Intact <br />: <br />Y ! N <br />< ? $ a DIS TABLE #4 Signature <br /> 9z <br />?r °D a € <br />z N Frequency: _5 Y ! N <br />Match LAB ID <br /> YIN <br />MATRIX ~ r <br /> <br />C3 <br />? <br />? <br />? <br />® 15 day turn around <br />Water [I C3 [3 ® ? ? ? <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? - <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? \l <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />Date/Time: fo)/?l /iU <br />Date/Time: 121201 10 Shipped by: Received by: 13;2 <br /> Received by: Date/Time: <br />Date/Time: Shipped by: <br />Y USE ONLY <br />Lp,BORATOR <br /> 11 Lab Disposal ® Sample T e # of fractions <br />Return to Client