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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 />T <br />N <br />?n <br />(D <br />N <br />w <br />0 <br />N <br />Company Name: Cotter Corporation Project Name: Schwalrtz <br />Tracking No. 3692013 61575841 DATE: _3/11/11 SSTF: S25645 & S25647 <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 1-719-371-3409-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 ? C. <br />.49 RUSH sample <br />r <br />l f <br />b <br />itt Rece14 mp <br />° <br />Other r su <br />m <br />a <br />o C <br />Special Report Formats - ELI must be notified 1.. <br />o a additional charges Co ID s) <br />prior to sample submittal for the following: f k <br />51 1 3 f? ¢ and scheduling <br /> 41 <br />NELAC ? A2LA ? Level IV ? '6 Comments: Cus ody Seal <br />Other ?? a <br />E a 7 e cc <br />S&A Schedule Code : YIN <br />EDD/EDT ? Format ?a E Intact <br /> z N GW CODE: Y I N <br /> <br />SAMPLE <br />; i l 4. <br />N LL = Signature <br />Y I N <br />IDENTIFICATION Collection Collection N Z <br />Fre uen Match LAB ID <br />(Name, Location, Date Time m Y I N <br />Interval, etc <br />MATRIX a <br />t Mine Refill Water 3/24111 9:20 Water ? ® ? ? ? ? O ? ? ? ® ? Table 2 <br />2 MW-6 3/25/11 10:50 Water ® ? ? ? ? ? O ? ? ? ® ? Table 2 <br />3 ? ? ? ? a a a ? ? ? ? ? <br />4 ? ? ? ? a a a ? ? ? ? a <br />e ? ? ? ? ? ? D ? ? ? ? ? <br />s ? ? ? ? ? ? ? ? ? ? a ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? <br />e ? ? ? O a ? ? D ? ? ? ? <br />s O ? ? ? ? ? ? ? ? ? a ? <br />?o ? ? ? ? ? ? ? a ? D ? ? <br />Custody Relinquished by: Bob Tennant Date/Time:3/25111 14:30 Shipped by: Received by: <br />Record Relinquished by: Date/Time: Shipped by: ime: <br />Received by: Z <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® <br />LABORA E ONLY <br />RY <br /> Sample Type # of fractions