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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 />lD <br />W <br />Cn <br />0 <br />w <br />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No. 3692013 00180250 DATE: 3101111 SSTF: 525651---S25658 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Randy Whicker 1-303-642-3893 mine phone <br />PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 210 Bob Tennant 1-719-371-3009-cell <br />Invoice Address: Invoice Contact: JoAnne Ary Purchase Order #: ELI Quote <br />PO Box 1750 Tel: 1-719-275-7413 ext. 209 <br />Canon City, CO 81215-1750 Fax: 1-719-275-1669 <br /> Notify ELI prior to <br /> <br />Report Required For: POTWNWVTP ? <br />_' <br />RUSH sample Receipt Te p <br />L <br /> <br />Other <br /> <br />° <br />submittal for o C <br />' <br /> <br />ID s) <br />Coollur <br />Special Report Formats - ELI must be notified .. a additional charges <br />prior to sample submittal for the following: _m '' <br />~> <br />P w <br />° <br />ul t and schedulin <br />Custody Sea! <br />NELAC C1 A2LA ? Level IV El W ' <br />E $ e Comments: Y / N <br />Other <br />EDDIEDT [I Format <br />0 Q <br />01 <br />S&A Schedule Code : <br />Intact <br /> 1 <br />z 5t <br />DE ? 1 <br />' YIN <br /> ' <br />8 T b <br />e <br />SAMPLE ` 1 ? o m l <br />O <br />Frequency 1 Signature <br />Y / N <br />IDENTIFICATION Collection Collection d1oo1 N a , Match <br />LAB ID <br />(Name, Location, Date Time j N Y <br />/N <br />Interval etc MATRIX <br />SW AWD 3101/11 11:15 Water ? ? ? ® ? ? ? ? ? ? ® ? Table 1 <br />2 SW A001 3/01/11 11:30 Water ® ? D ? 01 0 ? ? ? ? ® ? Cade 1 <br />3 SW BDIS 3/01/11 12:45 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />4 SW PL 3/01/11 12:55 Water ® ? D ? ? ? ? ? D ? ® ? Code 1 <br />5 SW OS 3/01/11 13:00 Water 0 10 ? ? ? ? ? ? ? ? ® ? Code 1 <br />s SW BOS 3/01111 14:20 Water 0 10 ? ? ? ? ? ? ? ? ® ? Code 1 <br />SW GS 3/01/11 14:25 Water ® ? ? D ? ? ? 0 10 ? ® ? Code 1 <br />e SW BPL 3/01/11 14:35 Water ? ? D ® 0 10 ? ? ? ? ® ? Table 1 <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? ? D ? ? ? ? ? <br /> <br />Custod Relinquished by: Bob Tennant Date/Time:3/02/11 <br />rX <br />Shipped by: <br />pped y: Received b Date ime: <br />1 <br />y 16:00 I <br />Record <br />MUST be Relinquished by: DatelTime: Shipped by: Received by: DatefTime: <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br /> Sample Type # of fractions <br /> <br />