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<br />v <br />CD <br />0 <br />rn <br />E.lV.''; <br />Chain o ustod ajd ??nWim[ quest <br />PLEASE PRA; provide as mucirgomt &n as posflie. Rgier to corresponding <br />. <br />Record <br />notes on reverse side. Page 1 of I <br />cay"wWame: Cotter Corp n Project Name: Sc atltrj?ltanitoring Program - Ischarga <br />* <br />Tracking Nb. 3692013_0017. DATE: _12/16/10 am <br />Report it Adc+bss: <br />Sampli'#isme itgitl+er than Contact: <br />Cotter Corporation - Mill Conbd Name?.Kri$ty Usn,Wc <br />PO Box 1750; fyanon. , 812217§0 Voice: 1-719-2754*13 exti- 213 Bob Tennai? <br />Invoice Mss: Invoice Contact: Kdsty Usnick Purchase order* Eft Quote #: <br />PO Box'?56 Tel: 1-719-275-7413 ext. 213 <br />Canoturity, C081215-1750 Fax: 1-719-275-1669 <br /> Notify ELI prior to Receipt Temp <br />RepoQ Required For: POTWNVWTP ? RUSH sample z , C <br />' <br />Other <br />E submittal for <br />es <br />har <br />l <br />i -- <br />- <br />Cooler I (s) <br />Special Report Formats - ELI must be notified <br />: <br />le submittal for the followin <br />rior to .. <br />.00 >1 g <br />c <br />pna <br />a a <br />and scheduling <br />g <br />p <br />samp I <br />t Custody Seal <br />NELAC [I A21-A [I Level IVY °'w $ <br />1 e s: <br />Commen Y / N <br />Other <br />EDD/EDT Format 3 <br />g a $ ? <br />a E e S&A Schedule Code Intact <br />Y/ N <br /> z m <br />8 o <br />co a € = DIS CODE #2 Signature <br />SAMPLE 1 ; Cd 0 Frequency: _1 Y / N <br />IDENTIFICATION Collection Collection a1ao1 U) W W Match LAB ID <br />(Name, Location, Date Time s .2 , a Y / N <br />Interval, etc MATRIX <br />DIS-001A--A 12/14/10 com osite Water ® ? ? ? ? ? ? ? ? ? "Cl ? <br /> <br />2 DIS-001A-B 12/15/10 com hosite water ® C1 ? ? ? ? ? ? ? ? ® ? <br />3 DIS-001A-C 12/16/10 8hr <br />composite water ® ? ? ? ? ? ? ? ? ? 01 0 ` <br />4 ? ? ? ? ? ? ? ? ? ? ? ? it <br />S ? ? ? ? ? ? ? ? ? ? ? ? y-.. <br />6 ? ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? Q ? ? <br />j <br />a ? O ? ? 0 ? 'V' 0 d ? ? ' <br />9 ? ? <br />T <br /> <br />? <br /> <br />Q <br /> <br />-?i ] <br /> <br />? . <br /> <br />i7 <br /> <br />? .. <br /> <br />. 0 <br /> <br />? <br /> <br />? <br /> <br />? <br />10 ? ? ? ? 0 ? ? ? Tjo Q 0 ? <br /> Relinquished by: Bob Tennant Date4Time: 12/16/10 Shipped by. Received at !Time:17--1 <br />Custody 17:30 <br />Record Relinquished by: Daterrime: Shipped by:tX Received Date/Time: <br />MUST be LABbRATORY USE ONLY <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® >L` Type _ # of fractions <br />t? <br />