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Chain of Custody and Analytical Request Record <br />=U =MMIM PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of .1 <br />D) <br />(Q <br />(D <br />N <br />Cn <br />0 <br />N <br />Q0 <br />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No. 3692013 DATE: 3/10111 SSTF: S25686--- 525688 <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 1-719-371-3009-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: POTW1VWVrP ? RUSH sample R <br />Other <br />Special Report Formats -ELI must be notified <br />: <br />followin <br />th <br />itt <br />l f <br />o 1 <br />I • <br />0 <br />? <br />o <br />V <br />r <br />? submittal for <br />Q additional charges <br />t and scheduling <br />Cg?le <br />ll'' <br />g <br />or <br />e <br />a <br />prior to sample subm <br />C1 y' w <br />o $ F Comments: Custed+y Seal <br />NELAC ? A21-A C1 Level IV <br />Other <br />EDD/EDT [l Format 4 <br />Z S&A Schedule Code : Intact <br /> <br />° <br />< SW CODE 13 <br />= Table 1 Y / N <br />Signature <br />SAMPLE l <br />i ? 11 Z Frequency 4, <br />IDENTIFICATION Collection on <br />Col <br />ect <br />Match LAB ID <br />(Name, Location, Date Time > j <br />12 <br />Y / N <br />Interval etc MATRIX <br />' SW FBRG 3/10/11 9:05 Water ? ® 0 ? ? ? D ? ? ? ® ? Code 3 <br />s SW ARH 3110111 9:20 Water ? 0 10 ? ? ? 0 ? ? ? IR ? Code 3 <br />3 SW LLHG 3/10/11 9:40 Water ? ? ? 0 ? ? ? 0 ? O ® ? Table 1 <br />4 ? ? ? ? ? ? 0 ? ? ? ? ? <br />5 ? ? ? ? ? ? ? ? 0 ? 0 ? <br />e ? ? ? 0 ? ? D ? ? 0 ? ? <br /> 0 ? ? ? ? ? ? 0 ? 0 ? ? <br />e ? D ? ? ? ? ? ? ? a ? <br /> 13 ? ? 0 ? ? ? ? ? a ? <br />s <br /> ,D ? ? b [1 0 13 ? ? ? ? ? <br /> Custody Relinquished by: Bob Tennant Date/Time:3110/11 15:30 Shipped by: -1-04 Ft, Received b : <br /> Record Relinquished by: DatelTime: Shipped by :. ed by: Date/Time: <br /> MUST be <br />Signed LABORATORY USE ONLY <br />Sample Disposal: Return to Client ? I-ak gle T e # of fractions