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N <br />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 />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No. _3692013 00180137 DATE: _1/27/10 SSTF: S25575 & S25576 <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 />Report Required For: POTWNVWTP ? RUSH sample Receip Temp <br />Other submittal for ° C <br />Special Report Formats - ELI must be notified o F additional charges C IePq,D( } <br />prior to sample submittal for the following: a M C a and scheduling ( 1 <br />NELAC A2LA [I Level IV C1 Comments: Custodal <br />? ? ? a - 3 <br />a m SBA Schedule Code : YyS <br />Other e <br />Intact <br />EDD/EDT ? Format i of E to E GW CODE: Y / N <br />= Signature <br />SAMPLE 0 Y I N Cr. IDENTIFICATION Collection Collection W W Fre uen Match LAB ID <br />(Name, Location, Date Time Y / N <br />m <br />Interval, etc) MATRIX <br />-1 1/27111 10:25 Water ® ? ? ? ? ? ? ? ? ? ® ? Table 2 <br />2 MW-2 1128111 10:30 Water ® ? ? ? ? ? ? ? ? ? ® ? Table 2 <br />3 ? ? ? ? ? ? ? ? ? ? ? ? <br />4 ? ? ? ? ? ? ? ? ? ? ? ? <br />5 ? ? ? ? ? ? ? ? ? ? ? ? <br />6 ? ? ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? _ <br />a ? ? ? ? ? ? ? ? ? ? ? ? <br />s ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? ? ? ? ? ? ? ? <br />Relinquished by: Bob Tennant Datefrime:1128111 Shipped by: Received by. ate/Time: <br />Custody 13:30 <br />Record Relinquished by: Date/Time: Shipped by: Received by: DatelTime: <br />MUST be LABORATORY USE ONLY <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® Sam le T e # of fractions