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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 />n <br />Company Name: Cotter Corporation Project Name: Schwartzwalder Water Monitoring Program - 01soMMe <br />Tracking No. _3692013_00179902 DATE: _11/19/10 SSTF; S25439 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick <br />PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 213 Bob Tennant <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 /> agarAL y :> Notify ELI prior to Recej?tTe <br />Report Required For POTWNVWTP ? o RUSH sample .5 C <br />Other a submittal for Co er ID(s <br />Special Report Formats - ELI must be notified = o <br />iv >1 a additional charges <br /> <br />hediaWn <br />and <br />prior to sample submittal for the following: co '6 <br />= , <br />>a o 3 <br />= sc Custody S-eal <br />? <br />NE LAC El A2LA El Level IV at,? y <br />n 120 o = Comments: Y/ <br />Other <br />EDD/EDT (:1 Format y a <br />? rn <br />'- 10 S&A Schedule Code : Intact <br />Y / N <br /> a <br />z <br />94 9 <br />m a € = DIS CODE 42 <br />x Signature <br />SAMPLE 8 ,s N M 0 Frequency: _1 Y/ N <br />IDENTIFICATION Collection Collection aim co J Match LAB ID <br />(Name, Location, Date Time g Y / N <br />Interval etc MATRIX <br />' DIS-001A-A 11/17/10 composite <br />Water <br />01 <br />0 <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />® <br />? <br /> <br />.:> <br />2 DIS-001A---B 11/18110 water ® ? ? ? ? ? ? ? 1:1 ? ® ? <br /> composite ite <br />3 DIS-001A---C 11/19/10 8hr water ® ? ? ? ? ? ? ? ? ? ® ? ?2 <br /> com site <br />4 ? ? ? ? ? ? ? ? ? ? ? ? .:.._ <br />a <br />5 ? ? ? ? ? ? ? ? ? D ? D <br />6 ? D ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? <br />e D ? ? ? ? D ? ? ? ? ? ? <br />9 ? ? ? ? ? ? D ? ? ? ? ? <br />10 ? ? ? ? ? ? ? ? 0 .0 ? ? <br /> Relinquished by: Bob Tennant Date/Time: 11/19/10 Shipped by Receiv y: Date/Time: <br />Custody 16:3a <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 />lC?-tit