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N <br />(L] <br />CD <br />CT <br />O <br />rn <br />LARD TORIES <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 Project Name: Schwartzwalder Water Monitoring Program - Discharge <br />Tracking No. 3692013_001800#&-Y•S DATE: _12/31/10 SSTF: S25552 <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 Bob 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 /> <br />r to <br />Notify ELI pri <br />Report Required For: POTWNWVfP [1 6 RUSH sample Receipt Temp <br />Other a submittal for 13 121 <br />??' C <br /> <br /> <br />Special <br />Re <br />Report Formats - ELI must be notified .. d o <br /> <br />>1 <br />a I= additional charges Cooler ID s <br />1 <br />k <br />L <br />prior to <br />sample submittal for the following: C ; do i and scheduling C <br /> <br />NELAC ? A21-A ? Level IV ? <br />aN <br />i; <br />g Comments: Custody <br />I <br />Y/ <br />Other <br />EDD/EDT ? Format E 3 <br />? y e <br />3 S&A Schedule Code : Intact <br /> i Z ~ DIS CODE 92 Y / N <br />SAMPLE N 03 a <br />w € <br />$ = <br />Frequency: <br />1 Signature <br />Y / N <br />IDENTIFICATION Collection Collection in o _ Match LAB I D <br />(Name, Location, Date Time g s <br />:3 <br />12 <br /> <br />N <br />Y/ <br />Interval, etc MATRIX <br />1 DIS-001A-A 12/27110 cam hosite Water ® ? ? 13 ? ? ? ? ? ? ® ? <br />DIS-001A-B 12/29110 8hr <br />composite water ® ? ? ? ? ? ? ? ? ? ® ? <br />3 DIS-00IA--C 12/31110 8hr <br />composite water ® ? ? ? ? ? ? ? ? ? ® ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />5 ? ? ? ? ? ? ? ? ? ? ? ? <br />e ? ? ? ? ? ? a ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? <br />a ? ? ? ? ? ? ? ? ? ? ? ? <br />9 ? ? ? ? ? ? ? ? ? ? ?. ? <br />10 ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />Custody <br />y Relinquished by: Bob Tennant Date/Time: 12/31/10 Shied b <br />pp y: <br />R roe y: DatefTime:1? 4 •y• 11 <br /> 17:30 <br />Record <br />Ml"ST be Relinquished by: Date/Time: Shipped by: Received by: Date/Time: <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal 0 LABORATORY USE ONLY <br /> Sample Type # of fractions <br />IM