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JAjW 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 />T <br />v <br />(L? <br />(D <br />N <br />d1 <br />0 <br />w <br />0 <br />Company Name: Cotter Corporation Project Name: Schwartzwaider Water Monitoring Program - <br />Tracking No. 3692013 00179902 DATE: -11/18/10 SSTF: S 25436--S25438 <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 /> <br />Report Required For: POTWMNYTP ? <br />RUSH sample Receipt Temp <br />o <br />3 t <br />Other m I ?, submittal for ? C <br />Special Report Formats - ELI must be notified o i # w o ¢ F additional charges Coole f ID(s <br />prior to sample submittal for the following: gm , w o Q t C and scheduling <br />NELAC El A2LA ? Level IV L1 ay a s o L 2 m o Comments: Custod? Seal <br />Other a <br /> <br />EDDIEDT El Format <br />' <br />i <br />i <br />? <br />7 <br />S&A Schedule Code : Intact <br /> p°O °4 s 3 SW CODE i 1 YIN <br />SAMPLE i{ o a <br />led o a € <br />0 y Table i <br /> <br />F Signature <br />IDENTIFICATION Collection Collection o N Q z requency 1,2,3,4 YIN <br />(Name, Location, Date Time a Match LAB ID <br />Interval, etc MATRIX N Y I N <br />SW FBRG 11/18110 10:10 Water 2 M ? ? ? ? ? ? ? 0 ? Code1 <br />2 SW ARH 11/18/10 10:20 Water ? ? ® ? ? ? ? ? ? ® ? Table 1 <br />3 SW LLHG 11/19110 8:30 Water [? ? ? ? ? ? ? ? ® ? Code 1 <br />4 ? ? ? ? ? ? ? ? ? ? ? ? <br />5 ? ? ? ? ? ? ? ? ? ? ? ? <br />6 ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? 01 0 ? ? <br />8 ? ? ? ? ? ? ? ? ? ? ? ? <br />s ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />Custody Relinquished by: Bob Tennant Date/Time:1 If 19/10 <br />16:30 <br />Shipped by: <br /> <br />ived by: Date/Time: <br />Rece X122 lU <br />Record <br />MUST be <br />Relinquished by,, Date/Time: <br />Shipped by: <br />Received by: Date/Time: kO l <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br /> Sam to <br />ype # of fractions