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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 />(D <br />N <br />O_ <br />N <br />A <br />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No. _3692013 61575965 DATE: 3/30111 SSTF: 525671 & S25672 <br /> Sampler Name if other than Contact: <br />Report Mail Address: <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: POTWNWVTP ? RUSH sample Re <br />Other r submittal for <br />Special Report Formats - ELI must be notified <br />i <br />m E.. ffi F <br />t additional charges <br />t and scheduling Cq? r ID(s) <br />[ ' i?o L <br />ng: <br />ple submittal for the follow <br />prior to sa <br />A ? Level IV ? <br />NELAC ? A21 m ? $ Comments: Custody Seel <br />- <br />?? ? <br />N <br /> <br />YI <br />Other <br />EDD/EDT ? Format a <br />i ?i a SBA Schedule Code : <br />GW CODE: Intact <br /> E Y / N <br /> S <br />t <br /> <br />I LL <br />? <br />2 ure <br />igna <br />SAMPLE a1in? N N Y / N <br />IDENTIFICATION Collection Collection <br />Fre uen Match LAB ID <br />(Name, Location, Date Time m <br />YIN <br />Interval, etc) MATRIX <br />ti Sump-5 3/30/11 8:45 Water is O ? ? ? ? ? ? ? ? ® ? Table 2 <br />2 MW-7 3130/11 11:15 Water ® ? 101 0 ? ? ? ? ? ? ® ? Table 2 <br />3 ? ? ? ? ? ? ? ? ? ? ? ? <br />4 ? ? ? ? ? ? ? ? ? ? ? ? <br />5 ? ? ? ? ? ? ? ? ? ? ? ? <br />6 ? ? ? ? ? ? ? ? ? ? ? ? <br />4 <br />7 ? ? ? ? ? ? ? ? ? ? ? <br />s ? ? ? ? ? ? ? ? ? 0 10 ? <br />s ? <br />? ? ? O ? ? ? ? ? ? ? ? <br /> - ? <br />t ? ? <br />1 ? ? ? ? ? ? ? ? 13 <br /> <br />10 _ <br />Custody Relinquished by: Bob Tennant Datelrime:3/30/11 15:30 Shipped by: Received by: Date/Time: <br />Record Relinquished by: Date/Time: Shipped by: Vllf t" Re G Date/Time. <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ? lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions