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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 />W <br />O <br />0 <br />w <br />CD <br />Company Name: Cotter Corporation Project Name: Schwartz - 3 e ahnPIe - U, J 21171/ <br />Tracking No. 3692013 61575903 DATE: _3/16/11 SSTF: S2559 ---525600 <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 />Report Required For: POTWAMNTP ? RUSH sample Receipt Temp <br /> <br />Other <br />Special Report Formats - ELI must be notified <br />y <br />a <br />submittal for <br /> <br />f <br />dditi <br />l <br />h C <br /> <br />Coo ec ID(s) <br /> <br />rior to sam <br />l <br />b <br />itt <br />l f <br />th <br />f <br />ll <br />i .. <br />" <br />_ t a <br />ona <br />arges <br />c <br />p <br />p <br />e su <br />m <br />or <br />a <br />e <br />o <br />ow <br />ng: m <br />3 " <br />E <br />° $ and scheduling <br />NELAC ? A2 LA ? Level IV ? ° Comments: Custody <br />l <br />1 <br />Other $ c 47 <br />E <br />DD/EDT ? Format <br />a ? <br />E <br />E <br />S&A Schedule Code : <br />Intact <br /> <br />1 g SW CODE 11 / <br />N <br />SAMPLE 1 2 o ° <br />< 1 x Table 1 Signature <br />IDENTIFICATION Collection Collection z Frequency) 1, <br />T <br />l Y / N <br />(Name, Location, Date Time ti ?1 wo coo <br />ers Match LAB ID <br />Interval, etc MATRIX m > rr H Y / N <br />SW AWD 3116111 9:30 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />2 SW A001 3116/11 9:40 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />a SW BDIS 3116/11 9:50 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />4 SW PL 3/16/11 12:45 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />e SW OS 3116111 12:50 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />e SW BOS 3/16/11 13:00 Water ? ? ? ® ? ? ? Q ? ? ® ? Table 1 :. <br /> . <br />' SW GS 3116111 15:05 Water ® ? ? ? ? ? ? ? ? ? 01 0 Code 1 x <br />a SW BPL 3/16111 15:10 Water ? ? ? ? ? ? ? ? ? ? 01 0 Code 1 <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />,o ? ? ? ? ? ? ? ? ? ? ? ? <br />Custody <br />ord <br />R Relinquished by. Bob Tennant Datefrime:3/17/11 16:00 Shipped by: Rec d ate/Time: 3 f <br />ec <br />MUST be Relinquished by: Date/Time: Shipped by: Received by: Daterrime: <br />Signed Sample Disposal: Return to Client ? Lab Disposal 110 US # <br />OLY <br />N <br /> Sample Type <br />oof <br />actions <br />