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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 />v <br />CD <br />N <br />O <br />0 <br />N <br />N <br />Company Name: Cotter Corporation Project Name: Schwartzwalder Water Monitoring Program - <br />Tracking No. 3692013 00179902 DATE:-11/19110 SSTF: S25435 <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 81215-1750 Fax: 1-719-275-1669 <br /> NotPfy ELI prior to <br />Report Required For: POTW/WWTP ? RUSH sample <br />l f Rec?ipt,Tmp <br />Other or <br />submitta ?e t", C <br />Special Report Formats - EL! must be notified <br />l for the followin <br />: <br />l <br />itt <br />b <br />t <br />i KO > <br />_ m <br />9 <br />9 additional charges <br />a and scheduling Co le <br />g <br />a <br />o samp <br />e su <br />m <br />pr <br />or <br />NELAC ? A2LA ? Level IV ? „; <br />s a _ <br />a v t <br />I Comments: <br /> <br />I Custody'l <br />Other <br />EDD/EDT ? Format 1, 9 <br />' 01 <br /> <br />8 n 2 $BA Schedule Code : <br /> <br />GW CODE: Y/ <br /> <br />Intact <br /> z :3 <br />~ E YIN <br /> 1 nature <br />Si <br /> ? <br />. N g <br />SAMPLE U. z Y I N <br />IDENTIFICATION Collection Collection N Match LAB ID <br />(Name, Location, Date Time Frequency: Y I N <br />Interval, etc) 4 a <br /> MATRIX <br />Mine Refill Water 11!192010 11:15 Water ? ® ? ? ? 13 ? ? ? ? ® ? Table 2 7 <br />2 ? ? ? ? ? ? ? ? ? ? ? ? <br />3 ? ? ? ? ? ? ? ? ? ? ? ? <br />4 ? ? ? ? ? ? ? ? ? ? ? ? <br />5 ? ? ? ? ? ? ? ? ? ? ? ? <br />6 ? ? ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? <br />g ? ? ? ? ? ? ? ? ? ? ? ? <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? ? ? ? ? ? ? ? <br /> Relinquished by: Bob Tennant DatelTime:11/19/10 Shipped by: iv by Date/Time: <br />Custody 16:30 <br /> Relinquished by: Date/Time. Shipped b • f-_ f' eceiv y: terrime: zZ <br />MUST be <br />Signed <br />Sample Disposal: Return to Client Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions