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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 />CD <br />N <br />O <br />O_ <br />N <br />W <br />Company Name: Cotter Corporation Project Name: Schwartmaider Water Monitoring Program - <br />Tracking No. 3692013 00179926 DATE: _11105/10 SSTF: S25485 & S25486 <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 81215-1750 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 81213-1750 Fax: 1-719-275-1669 <br /> Notify ELI prior to <br />Report Required For: POTWMIWTP ? RUSH sample Receil;L.Iemp <br />Other submittal for <br />h C <br />Special Report Formats - ELI must be notified .. <br />0 ffi a arges <br />additional c Coo r s <br /> <br />le submittal for the following: <br />m <br />i <br />t 9 <br />a t ¢ and scheduling <br />p <br />or <br />o sa <br />pr " W <br />A ? Level IV ? <br />NELAC ? A21 Comments: Custody Seal <br />- <br />Other E d N ` = Y I N <br />EDD/EDT [] Format <br />d <br />i > E <br />i <br />; S8J\ Schedule Code : <br />GW CODE: Intact <br /> u 5 - Y I N <br /> W L € = Signature <br />SAMPLE :I <br />Z ` Y I N <br />IDENTIFICATION Collection Collection w ul F ue Match LAB ID <br />(Name, Location, Date Time m r a Y I N <br />Interval, etc) MATRIX ~ ~ <br />1 MW-3A 11113/10 10:05 Water ® ? ? ? ? ? ? ? ? ? ® ? <br />s NiW-6 11/23/10 13:45 Water ® ? ? ? ? ? ? ? ? ? ® ? _ <br />3 ? ? ? ? ? ? ? ? ? ? ? ? <br />4 ? ? ? ? ? ? ? ? ? ? ? ? <br />5 ? ? ? ? ? ? ? ? ? ? ? ? <br />s ? ? ? ? ? o ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? _ <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />e <br />g ? ? ? ? ? ? ? ? ? ? ? ? <br />l0 ? ? ? ? ? ? ? ? ? ? ? ? <br /> Relinquished by: Bob Tennant Date/Time:11/24/10 <br />Shipped by: <br />Received b ? Dat !me: <br />Custody 16:30 <br />UST b Relinquished by: Date/Time: Shipped by: Received by: DateMme: <br />e <br />M <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions