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AMU 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 />.U <br />N <br />O <br />N <br />0 <br />N <br />O <br />Company Name: Cotter Corporation Project Name: Schwartzwaider Water Monitoring Program - <br />Tracking No. 3592013 00179919 DATE: _11122110 SSTF: S 25477--S25484 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick 1-303-642-3893 mitre 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, POTWNWVTP ? <br />8 <br /> <br />' <br />RUSH sample Receipt Temp <br />?' C <br />Other a submittal for <br />Special Report Formats - ELI must be notified i; tk a < F additional charges Co4}er ID s) <br />prior to sam <br />le submittal for the followin <br />: ?m a w o 0 'F and schedulin <br />p <br />g <br />~ <br />° - g <br />Cust <br />d <br />l <br />NELAC ? A2tA ? Level IV D <br />Comments: <br />o <br />y a <br />Other <br />EDDIEDT ? Format <br />I a I d ° <br />iZ2 o <br />2 <br />"- 2 <br />r: e <br />E <br />StiA Schedule Code : Y 1 U <br />Intact <br /> z ° A z SW CODE 11 Y I N <br /> <br /> <br />SAMPLE <br />z x Table I <br />Frsquency 1 <br />4 <br />2 <br />3 Signature <br />YIN <br />IDENTIFICATION Collection Collection ¢'' " <br />s N a , <br />, <br />, <br />Match LAB ID <br />(Name, Location, Date Time ° k w <br /> <br />Interval etc <br />MATRIX x <br />rr e' Y I N <br />' SW AWD 11/22110 12:00 Water 0 ? ? ? ? ? ? ? ? ? ? Codel <br />2 SW AOO1 11122/10 12:10 Water 0 ? ? ? ? ? ? ? ? ? M ? Code 1 <br />a SW BDIS 11122/10 13:20 Water 0 ? ? ? ? ? ? ? ? ? ? Code 1 <br />SW PL 11/22/10 13:30 Water 0 ? ? ? ? ? ? ? ? ? O ? Code 1 <br />s SW OS 11122110 14:25 Water 0 ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />e SW BOS 11/22/10 14:35 Water IZ ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />' SW GS 11122/10 15:30 Water ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />a SW BPL 1112210 15:40 Water ® ? ? ? ? ? ? ? ? ? ? Code 1 <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? ? ? ? ? ? ? ? <br />C <br />stod Relinquished by: Bob Tennant DatelTime:11122110 Shipped by: Rec d y <br />DatelTime: <br />u <br />y 17:30 . <br />Record <br />MUST ST b t>e <br />Relinquished by. DatelTime: <br />Shipped by; <br />Received by: Date/Time: <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br /> Sam le Tuna # of fractions <br />:3b