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-o <br />v <br />c? <br />CD <br />0 <br />OD <br />E_ /?E/?GY <br />LA6C?R,4 TC )i:1F5 <br />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 />Company Name: Cotter Corporation <br />Tracking No. _3692013_00179933 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215-1750 <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215-1750 <br />Report Required For POTwwNTP ? <br />Other <br />Special Report Formats - ELI must be notified <br />prior to sample submittal for the following: <br />? <br />NELAC ? A21LA ? Level IV <br />Other <br />EDDIEDT ? Format <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />interval, etc) <br />DIS-001A <br />2 <br />3 <br />4 <br />s <br />6 <br />7 <br />e <br />9 <br />10 <br />Collection I Collection <br />Date Time <br />12/01/10 _ Shr <br />Mn^ <br /> Relinquished by: Bob Tennant <br />Custody 17:30 <br />Record Relinquished by: <br />MUST be <br />Signed Sample Disposal: <br />Project Name: Schwartzwaider Water Monitoring Program - Discharge <br />DATE: _12101110 SSTF: S2_ J'95J <br />C t ct' <br />Contact Name: Kristy Usnick <br />Voice: 1-719-275-7413 ext. 213 <br />Invoice Contact: Kristy Usnick <br />Tel: 1-719-275-7413 ext. 213 <br />Fax: 1-719-275-1664 <br /> <br /> <br />?_.o? <br />?m $ <br />> <br />0 <br />3a ? <br />a D <br />wa N a <br />o <br />z _ <br />N <br /> <br />aims <br />?'n ? <br />? <br />? M <br /> 1 ? a <br /> a r <br />MATRIX <br />Water ? ® ® ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? <br /> <br /> ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? <br /> 10 10 10 10 10 Col 13 <br /> , <br />Daterrime: 12101/10 S hipped by: <br />Date/Time'. <br />Return to Client ? <br />Shipped by: <br />Lab Disposal <br />Sampler Name if other than on a <br />1-303-642-3893 Schwartzwalder <br />Bob Tennant 1 719-371-3009 <br />Purchase Order #: ELI Quote #: <br /> Notify ELI prior to <br /> RUSH sample <br /> submittal for <br />es <br />h <br />l <br /> a arg <br />c <br />additiona <br /> t and scheduling <br /> 2 Comments: <br /> S&A Schedule God <br />DIS T <br />?n Y <br />z N (20 <br />Frequency: _5 <br /> <br />Receipt t Temp <br />X1.1.. ' C <br />Cooler ID(s) t <br />Custody ?a1 <br />Y / NN <br />Intact <br />Y/N <br />Signature <br />YIN <br />Match LAB ID <br />Y/N <br />® ? <br />? ? <br />a ? <br />? ? <br />? ? <br />? ? <br />? ? <br />? ? <br />? ? <br />? ? <br />Recej%a-by-' "bate/Time: 12.-2.1Q <br />Received by: Date/Time: l?C <br />LABORATORY USE ONLY <br />Comma TvnA # of fractions,