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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 />CD <br />N <br />O <br />0 <br />N <br />N <br />Company Name: Cotter Corporation Project Name: Schwartirwaider Water Monitoring Program - mcnarge <br />Tracking No. 3692013_001799`156 DATE: _12/07/10 SSTF: S25501 <br /> Sampler Name if other than Contact: <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick 1-303-642-3893 Schwartzwalder <br />PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 213 Bob Tennant 1 719-371-3009 <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 Receipt Temp <br />Report Required For: POTWM/WTP ? o <br />= RUSH sample <br />submittal for C <br />Other <br />Special Report Formats -Eli must be notified a <br />.2-0 ? <br />R <br />? <br /> <br />2 + i= <br />additional charges <br />and scheduling <br />t Cooler ID(s) <br /> <br /> <br />l <br />prior to sample submittal for the following: <br />AC ? A2LA ? Level IV ? , ,; <br />' > o <br />? N o <br />2 Comments: Custody Sea <br />Y / <br />NEL <br />Other s <br />n o 'a <br />r 1! >_ „ <br />E <br />S&A Schedule Code Intact <br />EDD/EDT Format =' ~ DIS TABLE #3 Y / N <br /> i o ? A = Signature <br />SAMPLE I as + ? z° Frequency: _5 Y / N <br /> <br />IDENTIFICATION <br />Collection <br />te <br />D <br />Collection <br />Time a, m. <br />'n <br />o <br />;o <br />(0 <br />N <br />m <br />/ <br />s vS <br />? <br />Match LAB 10 <br />Y/ N <br />(Name, Location, a M F W a <br />Interval etc MATRIX <br />DIS-001A 12/07/10 comhrsite Water El ? ? ® ? C1 ? ? D ? ® ? <br />2 ? ? ? ? ? ? D ? ? ? ? ? <br />3 ? ? ? ? ? ? ? ? ? ? ? ? -- <br />4 ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />5 ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />8 ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />7 ? ? ? ? ? ? o ? o ? ? ? t <br />a ? ? ? ? ? D ? ? ? ? ? ? <br /> ? ? ? ? ? ? D ? ? ? ? ? <br />e <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />,o <br /> Relinquished by: Bob Tennant Date/Time: 12/09/10 Shipped by: Received by: Date/Time: \2-\0 \ <br />Custody <br />Record 17;30 <br /> <br />Relinquished by: Date/Time: Shipped by: <br />Received b Date/Time: \?-. JD <br />Y: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions <br />