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Chain 4f? #o c1 Analq Cati;Wques# Record <br />PLEASE INT;nprorride as much infa n aspoWble. Refer to corresponding notes on reverse side. Page 1 of 1 <br />Company Name. Comer DorplxMon <br />Tracking No. _3692043 00180243 DATE: _2125/11 SSTF: 5250222 <br />ReportMail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Corftd Name: Randy Whicker 1-303-642-3893 mine phone <br />PO Box 1750; Canon City, CO 81215-1750 Vbbe: 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 7'19,275-7413 ext. 209 <br />Canon City, CO 81215-1750 Fax: 1-719-275-1669 <br /> Notify ELI prior to <br />Report Required For: POTWAIVWTP ? RUSH sample Receipt Temp <br />Other a submittal for 4-a G C <br />Special Report Formats - ELI must be notified <br />k <br />? 2 F additional charges Co I t ID(s) <br />1 <br />prior to sample submittal for the following: m y <br />19 a t ¢ and schedulin - <br />NELAC ? A2LA ? Level IV ? S Qy <br />9 Comments: Custody Seal <br />Other %3: <br />?- <br />¢ _ a e <br />co S Y fg <br />EDD/EDT El Format ; (' <br />pi <br />z 10 > <br />9 e <br />E S&A Schedule Code : <br />GW CODE: Intact <br />Y/ N <br /> g <br />SAMPLE I <br />col i <br />o = <br />N Signature <br />I <br /> <br />DENTIFICATION <br /> <br />Collection <br /> <br />Collection <br /> <br />N <br />J <br /> <br />N <br />J <br /> <br />Z <br /> <br />ac <br />Y/N <br />Math LAB ID <br />(Name, Location, Date Time Frequency: <br /> <br />Interval, etc) <br />a Y 1 N <br /> MATRIX <br />I Sump--1 225/11 9:10 Water ® ? ? ? ? ? ? ? ? ? ® ? Table 2 <br />2 O ? ? O ? ? ? ? ? ? ? ? <br />3 ? ? ? ? ? ? ? ? ? ? O ? <br />4 ? ? ? ? ? ? ? ? ? ? ? ? <br />5 ? O ? ? ? ? ? ? ? ? ? ? IG?D l <br />6 ? .? ? ? ? ? ? ? ? ? ? a <br />' ? ? ? ? O ? ? ? ? ? ? ? <br />8 ? ? ? ? ? ? ? ? ? ? ? ? _ <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? ? ? ? ? ? ? ? <br />Custody Relinquished by: Bob Tennant Date/Time:2/25/11 <br />13:30 , <br />Shipped by: i?"'? <br />Received by Date/Time: -5A <br />Record <br />MUST be Relinquished by: Datefrime: Shipped by: Received by: DatelTime: <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br /> Sample Type # of fractions <br />Z>