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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 />(D <br />N <br />CO <br />0 <br />w <br />v <br />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No. 3692013 00180151 DATE: _2/03/11 SSTF: 525602---S25608 <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 R <br />i <br />t <br /> <br />SH <br />l Tem <br />ece <br />p <br />?- <br />Report Required For. POTWNIWTP El samp <br />RU <br />e <br /> <br />Special Report OFohrmats - ELI must be notified <br /> <br />° <br />°o submittal for <br />< additional charges <br />C e `ID(s) <br />prior to sample submittal for the following: m Hi <br />s w <br />0 <br />0 0 <br />2 t and scheduling <br />Custody Seal <br />NELAC ? A2LA El Level IV ? at* v o C Comments: Y <br />Other <br />EDD/EDT ? Format <br />a a ?ioi <br />; <br />S&A Schedule Code : <br />Intact <br />Y I N <br /> d w x <br />0 SW CODE I I Si <br />nature <br />SAMPLE ;aA a Ca z 'm Table 1 <br />Frequency 1, g <br />Y / N <br />IDENTIFICATION Collection Collection Match LAB ID <br />(Name, Location, Date Time j ? Y / N <br />Interval etc MATRIX <br />SW AWD 2103111 8:00 Water ? ? ? ® ? ? D ? ? ? ® ? Table 1 <br />2 SW AOO1 2/03111 8:15 Water ® ? D ? ? ? ? D ? ? ® D Code 1 <br />3 SW BOIS 2103/11 9:40 Water ® ? ? ? ? ? ? ? D ? ® ? Code 1 <br />SW PL 2/03111 ? ? ? ? ? D ? ? ? ? ? ? No sample taken <br />5 Sw OS 2103/11 10:05 Water ® D O ? ? ? ? 0 10 ? ® D Code 1 <br />s SW SOS 2/03/11 10:15 Water N ? ? ? ? ? ? ? ? ? N ? Code 1 0 /19 <br />SW GS 2103/11 13:10 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />9 SW BPL 2/03111 13:20 Water ? ? D ® ? ? ? ? ? ? ® ? Table 1 <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? D ? D D ? D D ? <br /> <br />Custod Relinquished by: Bob Tennant Date/Time:2/04/11 <br />Shipped by: <br /> <br />F?j l Received b : at imp. <br />y 13:30 cx <br />Record <br />MUST be <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by. Date/Timw l? aZ <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions <br />