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Chain of Custody and Analytical Request Record <br />I ' PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of 1 <br />Company Name: Cotter GOrnoration Project Name: Schwartz - <br />Tracking No. _3692013 61575972 DATE: _3/30/11 SSTF: S25673 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215-1750 Contact Name: Randy Whicker <br />Voice: 1-719-275-7413 ext. 210 1-303-642-3893 mine phone <br />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 POTWNVWTP ? RUSH sample Rec p Temp <br />° <br />Other <br />Special Re rt Formats - ELI must be notified <br /> <br />Po s <br /> <br />.. <br />° 1, <br />a submittal for <br />additional charges <br /> <br /> <br />li <br />d <br />h <br />d <br />a C <br />Cooler l9(s) <br /> <br /> <br />11 iy"gL <br />prior to sample submittal for the following. <br />NELAC ? A2LA ? Level IV ? ? ? >t <br />N <br />'a a <br />I a <br />a t n <br />an <br />u <br />sc <br />e <br />Comments: <br />Custody Seal <br />Other <br />El W <br />131 <br />< a <br />N a <br />r i? <br />E <br />S&A Schedule Code : Y/N <br />Intact <br />Format <br />EDD/EDT Z GW CODE: Y / N <br /> <br /> LL ,? x Signature <br />SAMPLE mm, N N z Y/ N <br />IDENTIFICATION Collection Collection <br />Fre uen Match LAB ID <br />(Name, Location, Date Time ? Y / N <br />Interval, etc) MATRIX <br /> ? ? O ? ? ? ? D ? ? ? ? <br />2 MW-12 3131/11 12:50 Water ® ? ? ? ? ? ? ? ? ? ® ? Table 2 <br />3 ? ? ? ? ? ? ? ? ? ? ? ? <br />4 ? ? ? ? ? ? ? ? ? ? o ? <br />5 ? ? ? ? ? ? ? ? ? ? ? ? <br />6 ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? 11 <br />e ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />s ? ? ? ? ? ? ? D ? O ? ? <br />10 D ? ? ? O ? ? O O ? ? <br />Custody Relinquished by: Bob Tennant Date/Time:3/31/11 15:30 Shipped by: Received b : Date/Time: <br />Record Relinquished by: Date/Time: Shipped by: Recei te/Time: / - <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE O Y <br />Sample Type # of fractions