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CD <br />cn <br />0 <br />rn <br />rJ 92" Chain of Custody and Analytical Request Record <br />qqq <br />AFAMIMOMNYAW 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: Schwartrwaider Water Monitoring Program - Discharge <br />Tracking No. _369201300179940 DATE: !12/03/10 SSTF: S25299 <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 Gob 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 Receipj,Te <br />Hsamp4e (M Other <br />Report Required For: POTWNVWfP RUS <br />? a submittal for r ID s <br />e t a charges <br />Special Report Formats -ELI must be notifiedo additional c <br />>4 121 and schedu <br />pT!i rior to sample submittal for the following: m g Custody Peal <br />NELAC ? A2LA ? Level IV ? 12 Comments: <br />o3 a ? Y <br />Other ; E S&A Schedule Code : Intact <br />EDD/EDT CI Format `' o ~ DIS CODE #t2 Y / N <br />SAMPLE -a z Frequency: 1 Y / N <br />LMMAAT S ignature <br />IDENTIFICATION Collection Collection aim V) Match LAB ID <br />(Name, Location, Date Time Y I N <br />Interv al etc IX ~ <br />8hr <br />' DiS-001A---A 12/01/10 composite water ® ? ? ? ? ? ? ? ? ? 010 <br />s 8hr water ® ? ? ? ? ? ? ? ? D 0 ? -- <br />DIS 001A--B 12!02110 com e <br />s DIS-001A--C 12103!10 co 8hrs? water ® Q ? ? ? ? ? ? ? ? ? <br />a ? ? ? D ? ? O O O ? ? ? <br />? ? ? ? ? ? ? ? D ? ? ? 107. <br />s <br />e ? ? D ? ? ? ? ? ? ? ? ? <br />? D ? ? ? ? ? ? ? ? ? ? <br />e ? O ? ? ? ? ? ? ? ? ? ? <br />e ? ? ? D ? ? ? ? ? ? ? ? <br />1 1 <br />io <br />Relinquished by: Bob Tennant Date/Time: 12/03/10 Shipped by: Received b . ate/Time: <br />Custody 16:30 <br />Record Relinquished by: Date/Time: Shipped by: Received by: Date/Time: <br />MUST be LABORATORY USE ONLY <br />Signed Sample Disposal: Return to Client ? Lab Disposal Sample Type # of fractions