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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 />(Q <br />(D <br />N <br />0 <br />N <br />.co <br />Company Name: Cotter Corporation Project Name: Schwartzwalder Water Monitoring Program - Dischatrgo <br />Tracking No. _3692013_00179919 DATE: _11/22/10 SSTF: S25476 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick 1-303-642-3893 Schwartmalder <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 /> Notify ELI prior to Receipt Temp <br />Report Required For: POTWNVWTP ? _ RUSH sample , C <br />Other F submittal for <br />es <br />dditional char Cooler ID <br />Special Report Formats - ELI must be notified .. o g <br />a a <br />and scheduling C? <br />y <br />prior to sample submittal for the following: m I <br />Custod <br />NELAC ? A21-A [I Level IV ? " <br />a ?0 V Comments: Y <br />Other <br /> <br />EDD/EDT E] Format 3 -"l . <br />m <br /> <br />a <br />E 98 o <br />v, <br />-8 <br /> <br />e <br />E <br /> <br /> <br />&A Schedule Code <br />ABLE #3 <br /> <br />Intact <br /> <br />Y/N <br /> Z cc E"E DIS T <br />= Signature <br />SAMPLE $i ea M <br />U1 Z m Frequency: S Y/ N <br />IDENTIFICATION Collodion Collection N N Ir Match LAB ID <br />(Name, Location, Date Time o M Y / N <br />Interval etc MATRIX <br /> <br />DIS-001A 11122110 8hr • Water ? ? ? ® ? ? ? ? ? ? ? ® 15 Day turn around <br /> e <br />compos <br />2 ? ? ? ? ? ? 01 0 ? ? ? ? <br />3 ? ? ? ? ? ? ? ? ? ? ? ? <br />4 ? ? ? ? ? ? ? ? ? ? ? ? <br />5 ? ? ? ? ? ? ? ? ? ? ? ? <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? <br />e 1 1 ? ? ? ? ? ? ? ? ? ? ? ? <br />g - ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? ? ? ? ? D ? ? <br /> Relinquished by: Bob Tennant Datelrime: 11122/10 Shipped by: Rec i d y. ate/Time: <br />Custody <br />Y 17:30 <br />Record <br />ST b Relinquished by: Date/Time: Shipped by: Received by: Date/Time: <br />e <br />MU <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions