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AN 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 /> <br />v <br />(D <br />cn <br />0 <br />rn <br />Company Name: Cotter Corporation Project Name: Schwartzwalder Water Monitoring Program - Lon mrW <br />Tracking No. 3692013 DATE: -,_,11!05110 SSTF: $25287 <br />, Sampler Name if other than Contact: <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />CO 81215-1750 <br />PO Box 1750; Canon City Contact Name: Kristy Usnick <br />Voice: 1-719-275-7413 ext. 213 Bob Tennant <br />, ELI Quote <br /># <br />O <br />d <br />Invoice Address: Invoice Contact: Kristy Usnick : <br />er <br />r <br />Purchase <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 T qrnp <br />Report Required For. POTWNWVfP El <br />Other <br />a RUSH sample <br />submittal for <br />Coale ID s) <br />notified <br />t b <br />ELI additional charges <br />e <br />mus <br />Special Report Formats - <br />i <br />f <br />ll <br />h <br />o and schedulin al <br />Custod <br />ow <br />ng: <br />o <br />e <br />r to sample submittal for t <br />pr <br />A ? Level IV ? <br />NELAC ? A21 d y ' e Comments: y <br />Y <br />- <br />Other <br /> <br />E <br />s <br /> <br />~ S&A Schedule Code : <br /> <br />= Intact <br /> <br />Y/N <br />EDD/EDT [I Format o DIS CODE 02 <br /> z ID a € = Signature <br />SAMPLE ig a z° Frequency: 1 Y / N <br />IDENTIFICATION Collection Collection Match LAB ID <br />(Name, Location, Date Time o a Y / N <br />Interval etc MATRIX <br /> <br />DIS-001A---A 11/03110 com hosite Water ® ? ? ? ? ? ? ? ? ? ® ? <br />2 DIS-001A---B 11104110 water ® ? ? ? ? ? ? ? ? O ® ? <br /> composite - <br />3 DIS-001A----C 11/05/10 8hr <br />osite <br />com water ® ? ? ? ? ? ? ? ? ? ® ? <br /> <br />4 p <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? + <br />' O1! <br />5 ? ? ? ? ? ? ? ? ? ? ? ? <br />8 ? ? ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />e <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />B <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> 10 <br />Relinquished by: Bob Tennant Date(1 ime: 11/05/10 <br />Shipped by ? <br />R ceiv W/??Date/Time: <br /> Custod <br />Y 17:30 <br /> Record Relinquished by: Date/Time: Shipped by: Received by: Date/Time: <br /> MUST be <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions