Laserfiche WebLink
ZZA'FAWA 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 />4111112110 5,--- <br />Company Name: Cotter Corporation Project Name: Schwartzwaider Water Monitoring Program - umnairge <br />Tracking No. 369201300179926 DATE: _I 1/24/10 SSTF: 525487 <br /> Sampler Name if other than Contact <br />Report Mail Address: <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 /> Notify ELI prior to Receip T mp <br />Report Required For: POTWMNVfP El RUSH sample <br />submittal for C <br />Other <br />Special Report Formats - ELI must be notified e <br />1.. <br />1 ? <br />a additional charges C 1 D(s <br />l for the following: <br />itt <br />l <br />b 1 <br />0 <br />m <br />? <br />>? and scheduling <br />Custody Seal <br />m <br />a <br />e su <br />prior to samp <br />C El A&A ? Level IV ? <br />e <br /> <br />Comments: <br />r_ <br /> <br />YIN <br />NELA <br />Other a A ; E S&A Schedule Code : Intact <br />EDD/EDT ( ] Format ~ DIS CODE 02 Y I N <br /> i Signature <br />SAMPLE $ <br />x'°01 a M <br />w z Frequency: 1 Y I N <br />IDENTIFICATION Collection Collection <br />? <br />9 Match LAB ID <br />(Name, Location, Date Time .2 Y I N <br />Interval, etc MATRIX it 1 '' Q <br />' DIS-001A---A 11/22110 con8hr Water ® ? 11 ? ? ? ? ? ? ? ® ? <br /> <br />2 <br />DIS-001A---B <br />11/23110 <br />8hr <br />water <br />® <br />? <br />? <br />? <br />11 <br />? <br />? <br />? 1 <br />? <br />? <br />? <br />® <br />? <br /> composite <br />- <br />s DIS-001A---C 11/24110 8hr water ® ? ? ? O ? ? ? ? ? ® ? <br /> composite <br />a ? ? ? ? LO ? ? ? ? ? ? ? <br />s ? ? ? ? ? ? ? ? ? ? ? ? <br />s ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />7 ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />a <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />9 <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />10 <br /> Relinquished by: Bob Tennant Datefrime: 11/24/10 Shipped by: f x Received by L"'T ?ae ime: I 11 D <br />Custody 16:30 <br />Record Relinquished by: Datefrime: Shipped by: Received by: Datefrime: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />gam le T rum # of fractions