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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 />v <br />CD <br />N <br />O <br />N <br />0 <br />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No. 3692013 00180182 DATE: 2111111 SSTF: 525583---$25590 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick 1-303-642-3893 mine phone <br />PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 213 Bob Tennant 1-719-371-3009-cell <br />Invoice Address: Invoice Contact: Kristy Usnick Purchase Order ELI Quote #: <br />PO Box 1750 Tel: 1-719-275-7413 ext. 213 <br />Canon City, CO 81215-1750 Fax: 1-719-275-1669 <br /> Notify Eli prior to <br /> <br />Report Required For: POTWNVWTP ? <br />RUSH sample Receipt t Temp <br />o <br />C <br />Other <br />Special Report Formats - ELI must be notified 1 <br />g m <br />w W <br />$ a submittal for <br />F additional charges <br />h <br />d <br />li <br />d <br />t C le ID(s) <br />prior to sample submittal for the following: <br />NELAC ? A2LA El Level IV ? <br />y <br />o <br />m e <br />u <br />n <br />an <br />sc <br />'F Comments: <br />Seal <br />Custody <br /> 3 U < r <br />?``D <br />Other <br />EDD/EDT ? Format . <br />` a <br />$i Q <br />'v <o I SBA Schedule Code : ?\ <br />Intact <br /> ` <br />z o ae = SW CODE 11 Y / N <br /> <br />SAMPLE S ?, € <br />$ N Table 1 <br />Frequency! 1 Signature <br />Y / N <br />IDENTIFICATION Collection Collection s a , Match LAB ID <br />(Name, Location, Date Time Y ! N <br />Interval, etc MATRIX D ' re C* <br />SW AWD 2111!11 13:30 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />2 SW A001 2111111 13:40 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />a SW BDIS 2/11/11 13:45 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />SW PL 2111/11 14:25 Water ® ? ? ? ? ? ? ? ? ? IA ? Code I <br />s SW OS 2111111 14:30 Water ® ? ? ? ? ? ? ? ? ? ® O Code I <br />e SW SOS 2111/11 14:40 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />SW GS 2111111 15:15 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />e SW BPL 2111111 15:25 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />s ? ? ? ? ? ? ? 11 ? ? ? ? !kj <br />10 ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />Custody Relinquished by: Bob Tennant Date/Time:2111/11 <br />18:00 Shied by <br />PP Y <br />Rec Date/Time: 2,14,1k 1 <br />Record <br />MUST be Relinquished by: Daterrime: Shipped by: Received by: Date/Time: <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br /> Sample Type # of fractions <br />yj