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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 />n? <br />CD <br />N <br />W <br />O <br />N <br />rn <br />Company Name: Cotter Corporation Project Name: Schwart rwaider Water Monitoring Program - <br />Tracking No. 3692013 00179834 DATE: 10/29/10 SSTF: S25384---525385 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick 1-303-642-3893 mine phone <br />PO Box 1750; Canon City, CO 61215-1750 Voice: 1-719-275-7413 ext. 213 Bob Tennant 1-719-371-3009-cell <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 <br />Report Required For: POTWMNVTP ? RUSH sample Receipt <br />Temp <br />Other submittal for - <br />C <br />Special Report Formats - ELI must be notified = .. <br />' <br />? additional charges ) <br />Co r ID s <br />prito sample submittal for the following: a,-- <br />o' m ffi a and scheduling <br />NELAC El A2LA El Level IV C1 E M C j Comments: Custody Sea <br />Other <br />EDD/EDT ? Format <br />S&A Schedule Code : <br />Y 1 N <br /> C9 <br />z T E <br />E <br />GW CODE: <br />intact <br />Y/N <br /> <br /> 8 8 s Signature <br />SAMPLE <br />cot <br />U. <br />U. <br />z <br />Y/ N <br />IDENTIFICATION Collection Collection N n Match LAB ID <br />(Name, Location, Date Time m m Fr uen YlN <br />Interval, etc) a a <br /> MATRIX <br />' MW-00 10/292010 12:10 Water ® ? ? ? ? ? ? ? ? ? ® ? <br />s MW-0 10292010 14:55 water 01 0 ? ? ? ? ? ? ? ? ® ? <br />3 ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />5 <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? < i <br />8 ? ? ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? _ <br />8 ? ? ? ? ? ? ? ? ? ? ? ? <br />s ? ? ? ? ? ? ? ? ? ? ? ? <br />10 0- 1 ? ? ? ? ? ? ? ? ? ? ? <br /> <br /> <br /> <br />od <br />C quished by: Bob Tennant Date/Time:10/29/10 <br />Re1 Shipped by: r x_ Received by: ate <br />[Tim <br />e: <br />y <br />us <br />y 30 <br />Record <br />MUST be Relinquished by: Date/Time: Shipped by: Received by. DatelTime: <br /> <br />Signed <br />Sample Disposal: Return to Client ? lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions <br /> <br />?S?;