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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 />Company Name: Cotter corporation Project Name: Schwartz - <br />Tracking No. 3692013 00180175 DATE: _2/10/11 SSTF: S25580--- S25582 <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 Receipt Temp <br />Report Required For: POTWMWTP ? RUSH sample ?_` C <br />Other 13 submittal for Cooter ID(s) <br />Special Report Formats - ELI must be notified .. o F a additional charges CA u;A IL <br />prior to sample submittal for the following: Km H o U t and schedulin Custodl <br />NELAC ? A2LA [I Level IV El ti -23 0 ` a e Comments: Y43 <br />Other <br />; 10 < S&A Schedule Code : Intact <br />EDWEDT ? Format _ °uJ E Y / N <br />m o ?o _ : SW CODE 13 <br />l x Table 1 Signature <br />SAMPLE o Cd C i c* Frequency 4, Y/ N <br />Match LAB ID <br />IDENTIFICATION Collection Collection' o N < ce <br />(Name, Location, Date Time 9 W w Y/ N <br />Interval, etc MATRIX ' =) rr c* _1 1 -1 1 <br />SW FRRG 2/10111 8:50 Water ? ® 010 ? ? ? ? ? ? ® ? Code 3 <br />s SWARH 2/10/11 9:20 Water ? ? ? ® ? ? ? ? ? ? ® ? Table 1 <br />3 SW LLHG 2/10111 9:30 Water ? ® ® ? ? ? ? ? ? ? ® ? Code 3 <br />? ? 010 ? ? ? ? ? ? ? ? <br />5 ? ? ? ? ? ? ? ? ? ? ? ? ?(? <br />$ ? ? ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? <br />a ? ? ? ? ? ? ? ? ? ? ? <br />e ? ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? 110 ? ? ? ? ? ? ? ? ? <br />Relinquished by: Bob b Tennant Date/Time:2/10I11 <br />Custody Shipped by: Rec d y: Datefrime: <br />12:30 <br />Record <br />MUST be Relinquished by: Date/Time: Shipped by: Received by: Date ime: <br />Signed LABORATORY USE ONLY <br />? ® Sample Type # of fractions <br />Sample Disposal: Return to Client Lab DisPosal