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&MMY Chain of Custody and Analytical Request Record <br />J ' - 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 - <br />Tracking No. 3692013 00180007 + DATE: _12122/10 SSTF: S25535 & S25537 <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 /> Notify ELI prior to <br />Report Required For: POTWM w7p El <br />RUSH sample <br />Receipt Temp <br />Other submittal for ° C <br /> <br />Special Report Formats - ELI must be notified <br />R F <br />¢ additional charges Cooler ID(s) <br /> <br />ll <br />i <br />f <br />f b 9L0 ji <br />m p t Q and schedulin <br />ow <br />ng: <br />or the <br />o <br />prior to sample submittal W <br />P <br />> D a a t <br />ments: <br />C <br />Seal <br />Custod <br />NELAC ? A2LA ? Level IV ? ` <br />szYy? 14 om y <br />YIN <br />Other <br />EDD/EDT ? Format A < t <br />of ? <br />8 E <br />E SBA Schedule Code : <br />GW CODE: Intact <br />Y I N <br /> = <br /> I $ $ Signature <br />SAMPLE ;?m+ N N z YIN <br />IDENTIFICATION Collection + Collection m w <br />Frequency: Match LAB ID <br />(Name, Location, Date <br /> <br />I Time -1 <br />M -J <br />co <br />YIN <br />Interval, etc) MATRIX ~ i ~ <br />Domestic well 12/22110 9:45 Water ® ? ? 1 ? ? ? ? ? ? ? 0 10 <br />s MiN-7 12122!10 12:45 Water ® ? ? ? ? ? ? ? ? ? ® ? _ <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />5 ? ? ? S ? ? ? ? ? ? ? ? ? <br />e ? ? ? ? ? ? ? ? ? ? ? ? 1 <br />7 ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br /> ? a ? ? ? ? ? ? ? ? ? ? <br />s <br /> ? ? ? ? ? ? ? ? ? ? ? 0 <br />?o <br /> Relinquished by: Bob Tennant Date/Time:12l22/10 Shipped by: Received by , DateMme: i j? <br />Custody 17:30 <br />1 <br />Record Relinquished by: Date/Time: Shipped by: Received by: Date/Time: <br />MUST be <br />Signed <br />1 <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions <br />S