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Chain of C Request Record <br />ustody and Analytical <br /> <br />PLEASE PRINT; pro eSide. Page l of l <br />Refer t <br />vide as much information a possible, <br /> Project Name: Schwartzwalder Water Monitoring Program - Discharge <br />Company Name: Cotter Corporation SSTF: S25553 <br />Tracking No. _3692013_00180014 DATE: _12127110 <br />Sampler Name if other than <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill e <br />Contact Name: Kristy Usnick 1-303-642-3893 Schwartzw <br />13 Bob Tennant 1 719-37 <br />PO Box 1750; Canon City, CO 81215-1750 E <br />Voice: 1-719-275-7413 ext. 2 <br />Order #: ELI <br />Invoice Address: Invoice Contact: Kristy Usnick Purchase <br />PO Box 1750 Tel: 1-719-275-7413 ext. 213 <br />Canon City, CO 81215-1750 Fax: 1-719-275-1669 <br /> rior to <br />ELI <br />tif <br />N <br /> p <br />y <br />o <br />Receyp Tip <br /> <br />Report Required For: POTWNVWTP El <br />8 <br />= RUSH sample rt `? <br />submittal for <br />ID <br />Other 19 f a ( ) <br />additional charges r <br />F <br />Special Report Formats -ELI must be notified Tg >FJ <br />d o <br />a <br />t and scheduling <br />Custody,Seal <br />prior to sample submittal for the following: <br /> <br />? <br />Level IV <br />ELAC ? A2LA El r- 9: <br /> <br />ay <br /> <br />Y <br />?j <br />Comments: <br />N <br />Other <br />t <br />[I F A a s t <br />z con E S8A Schedule Code : Intact <br />DIS CODE #4 Y / N <br />orma <br />EDD/EDT z € = Signature <br /> I & m Y/ N <br />SAMPLE I N i Frequency: _5 <br />Match LAB ID <br />IDENTIFICATION Collection Collection 3 < Y / N <br />(Name, Location, Date Time ATRIX ~ <br />Interval etc M <br />A <br />' 12/27/10 Water ? ® ® ? ? ? ? ? ? ? ? ® 15 day turn around <br />DIS-001 composite <br />2 ? ? ? ? ? ? ? ? ? ? ? ? <br />3 ? ? ? ? ? ? ? ? ? ? ? ? _ <br /> <br />q ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />5 <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />6 <br /> ? ? ?/` <br /> ? ? ? ? ? ? ? ? ? ? <br /> <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />e ? <br /> ? ? ? ? ? ? ? ? ? ? ? <br />10 <br /> Relinquished by: Bob Tennant Date/Time: 12/27/10 Shipped by: Received by: Date/Time: <br />Custody 17:30 <br />iv %? Date/Time: <br />Re <br />. <br />Recorbe ipped by: <br />Relinquished by: Date/Time: Sh LABORATORY USE ONLY <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® Sam le T # of fractions