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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 />cc <br />CD <br />N <br />0 <br />W <br />co <br />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No. 3692013 61575934 DATE: _3/22111 SSTF: S25636---525643 <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 t Temp <br />i <br />R <br />ce <br /> l <br />RUSH p <br />, <br />Report Required For: POTWNWVTP ? e <br />samp ? <br />C <br />Other submittal for <br />h Cooler ID(s) <br />Special Report Formats - ELI must be noted <br />m <br />gm < arges <br />F additional c <br />h <br />d <br />li <br />d <br />t <br />ple submittal for the followin <br />rior to sa <br />9 <br />NELAC El AZLA ? Level IV 1:1 <br />w <br />o o <br />n <br />an <br />u <br />sc <br />e <br />Comments: <br /> <br />Custody S al <br /> z 2 m <br />Other <br /> <br />EDDIEDT El Format <br /> <br /><a <br />v <br /> <br />g <br />? <br />v <br />< <br />~ <br /> <br />S&A Schedule Code : <br /> <br />Intact <br /> z o SW CODE / 1 Y/ N <br /> 1 nature <br />Si <br />SAMPLE < x <br />S Table <br />Fiequencyl 1 g <br />Y/ N <br />IDENTIFICATION Collection Collection ° < , <br />Two coolers Match LAB ID <br />(Name, Location, Date Time ; H Y / N <br />Interval etc MATRIX <br />SW AWD 3/22/11 9:55 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />2 SW A001 3122/11 10:05 Water 01 0 ? ? ? ? ? ? ? ? ® ? Code 1 <br />3 SW BDIS 3122111 10:15 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />4 SW PL 3/22/11 11:30 Water 0 101 0 10 ? ? ? ? ? ? ® ? Code 1 <br />e SW OS 3122111 11:40 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />e SW BOS 3/22/11 11:50 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />SW GS 3/22/11 13:10 Water ? ? ? 0 10 ? ? ? ? ? ® ? Table 1 <br />e SW BPL 3/22/11 13:20 Water ® ? ? ? ? ? D ID- ? ? ® ? Code 1 <br />9 ? ? ? ? ? ? ? ? ? ? ? ? v?tJ <br />,o ? ? ? ? ? ? ? ? ? ? ? ? <br />4i <br />i <br />Custody Relinquished by: Bob Tennat'_tt Date/Time:3/22/11 16:00 Shipped by: Received by:( lg44 Datelrime: <br />Record Relinquished by: Date/Time: Shipped by: Received by: Date/Time: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample T e # of fractions <br />