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AEF 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 />-o <br />v <br />(D <br />co <br />0 <br />co <br />Company Name: Cotter Corporation Project Name: Schwartzweldeir Water Monitoring Program - DISCHSIIr9 <br />Tracking No. 369201300179896 DATE: _11117110 SSTF: S2434 <br /> Sampler Name if other than Contact: <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill Contact Name: Kfisty Usnick 1-303-642-3893 Schwartzwalder <br />PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 213 Bob Tennant 1719-371-3009 <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 /> ELI prior to Recent <br /> <br />Report Required For: POTWIWUIITP ? <br />sample <br />tal for <br />) <br />YT, <br />Other <br />Special Report Formats - ELI must be notified <br />c >1 F <br />nal charges <br />li <br />d <br /># <br />F C tpq 10( <br /> <br /> <br />o sample submittal for the following: <br />prior t s <br /> <br />9 n <br />le <br />u <br />ents: <br /> <br />Custody Seal <br />NELAC ? A2LA ? Level IV ? Q Y <br /> <br />Other <br />EDDlEDT [] Format <br />E <br /> <br />hedule Code <br />E <br />DE #4 <br />Intact <br /> <br />Y f N <br /> Z g ?, a M <br />i° <br />E Signature <br />SAMPLE ; M 10 Frequency: 4 Y I N <br />IDENTIFICATION Collection Collection m Match LAB ID <br />(Name, Location, Date Time Y I N <br />Interval etc MATRIX _ <br />' DIS-001A 11117110 COn8hr fte Water ? O IM ? ? ? ? ? ? ? ? <br />Z ? ? ? ? ? ? ? ? ? ? ? ? <br />3 ? ? ? ? ? ? ? ? ? ? ? ? <br />4 ? o ? ? ? ? ? ? ? ? ? ? <br />s ? a ? ? ? ? ? ? ? ? ? ? <br />6 ? ? ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? <br />B ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? O ? ? ? ? ? ? ? ? ? O <br />9 <br /> 0 10 10 0 ? ? ? ? ? ? ? ? <br />10 : <br /> Relinquished by: Bob Tennant Date/Time: 11/17110 Shipped by, Received by: Datemme: <br />Custody 17:30 <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 (? LABORATORY USE ONLY <br />Sample Type # of fractions <br />