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Chain of C <br />PLEASE PRINT; pro ustody and Analytical Request Record <br />vide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of 1 <br />Company Name: Cotter Corporation <br />Tracking No. _3692013_00180007 Project Name: Schwartzwaider Water Monitoring Program - Discharge <br />DATE: _12/22110 ssTF: S25535 <br />me if other than Contact: <br />N <br />l <br />Report Mail Address: <br />Cotter Corporation - Canon City Milt <br />1750 <br />1215 Contact Name: Kristy Usnick <br />Voice: 1-719-275-7413 ext. 213 a <br />er <br />Samp <br />Bob Tennant <br />- <br />PO Box 1750; Canon City, CO 8 der* <br />O ELI Quote #: <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215-1750 Invoice Contact: Kristy Usnick <br />Tel: 1-719-275-7413 ext. 213 <br />Fax: 1-719-275-1669 r <br />Purchase <br /> rior to <br />ELI <br />tif <br />N <br /> p <br />y <br />o Receipt Temp <br />Report Required For: POTWWWTP ? <br />Other <br />Special Report Formats - ELI must be notified <br /> <br />-2.e g RUSH sample <br />submittal for <br />t additional charges <br />and scheduling , C <br /> <br />Co r,IQ s} <br /> <br />( <br />Seal <br />d <br />t <br />prior to sample submittal for the following: <br />A2LA [I Level IV El <br />NELAC ? <br />Other <br />EDD/EDT ? Format 0; <br />aN <br /> <br />z i <br /> <br />N <br />a <br /> <br /> <br />„ <br /> <br />; <br />~ c <br /> <br />E <br />Comments: <br />S&A Schedule Code : <br />DIS CODE #2 y <br />o <br />Cus <br />Y I N <br />Intact <br />Y I N <br />Signature <br />S A M P L E <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc Collection <br />Date Collection <br />Time S <br />'aims <br />MATRIX 06 <br />.- <br />A m <br />(a <br />~ Frequency: 1 Y I N <br />Match LAB ID <br />Y I N <br />001A---A <br />DIS 12/20/10 h Water ® ? ? ? ? ? ? ? ? ? ® ? <br />- osite <br />com <br />2 DIS-001A---B 12/21110 8hr <br />corn osite water ® ? ? ? ? ? ? ? ? ? ® ? _ <br />001A---C <br />3 DIS 12/22/10 8hr water ® ? ? ? ? ? ? ? ? ? ® ? <br />- corn osite <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> g <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> 8 <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br /> <br /> 'o ? <br />? <br /> Relinquished by: Bob Tennant D ate/Time: 12/22/10 Shipped by: 7 <br />G <br />Received b : L17e?Time: . <br /> Custody 17:30 <br />Record <br />MUST be Relinquished by: D <br />Signed Sample Disposal: Re <br /> <br />ate/Time: Shipped by: <br />turn to Client ? Lab Disposal ® Received by: Date/Time: <br /> <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />