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AMU 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 />c? <br />Company Name: Cotter Corporation Project Name: Schwartzwaider Water Monitoring Program - Discharge <br />Tracking No. 3692013_00179865 DATE: _11/04110 SSTF: S25286 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy 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 /> Notify ELI prior to Re <br /> <br />Report Required For: POTwNvwTP ? <br />- <br />RUSH sample Mr4v' <br />Other <br />Special Report Formats - ELI must be notified <br />a .. a I submittal for <br />Q additional charges ( ? <br />Co a ??? <br />prior to sample submittal for the followin <br /> <br />' <br />? .,to <br />4 <br />h <br />? <br />o and scheduling <br />t? <br />' <br />Custody Seal <br />? <br />NELAC [:1 A2LA ? Level IV N ? ? S Comments: Y <br />Other <br /> <br />-1 Format <br />EDD/EDT a ?' d <br /> <br /> <br />$ict E <br /> <br /> <br />?- <br />S&A Schedule Code : <br /> <br /> <br />DIS CODE #4 Intact <br /> <br /> <br /> <br />IN <br /> z a S = Signature <br />PLE <br />A I k N 0 4 YIN <br />M <br />S B Frequency: <br />IDENTIFICATION Collection Collection ai0 (ft <br />g <br />Match LAB ID <br /> <br />(Name, Location, <br />Date <br />Time <br />g <br />g <br />Q co <br />C <br />YIN <br />Interval etc MATRIX <br />' DIS-001A 11/04/10 Comhrsite Water ? ® ® ? ? ? ? ? ? ? ? <br />2 ? ? ? ? ? ? ? ? ? ? ? ? <br />3 ? ? ? ? ? ? ? ? ? ? ? ? <br />4 ? ? ? ? ? ? ? ? ? O ? ? <br />s ? D 0 .0 ? ? 10 10 ? ? O ? <br />6 ? ? ? a a ? ? O ? a ? ? l> i'I <br />7 ? ? 0 10 10 ? ? ? ? ? O ? <br />6 ? ? ? ? ? ? ? ? ? D ? ? <br />9 ? ? ? ? O ? ? 0 10 10 ? ? <br />,p 00 O ? 0 0 ? 0 10 10 0 0 <br /> Relinquished by: Bob Tennant Date/Time: 1110 10 Shipped by: Rec ive e, Date/Time: 1/'J <br />Custody 17:30 <br />Record <br />ST b Relinquished by: ate/Time: t f Oi =T0 Shipped by: Received by: Date/Time: <br />e <br />MU <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions