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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 />v <br />CD <br />N <br />0 <br />N <br />w <br />Company Name: Cotter Corporation Project Name: Schwartzwaider Water Monitoring Program - Discharge <br />Tracking No. _3692013_00179872 DATE: - 91/10/10 SSTF: S25395 <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 <br /> <br />Report Required For: POTWIWVVrP ? <br />RUSH sample Receipt Temp <br />Le <br /> <br />Other <br />Special Report Formats - ELI must be notified <br /> <br />i <br />t <br />l <br />i <br />l f <br />h <br />f <br />l <br />b <br /> <br />I $ <br />..o <br />submittal for <br />a additional charges C <br />Coo r ID s <br />pr <br />or <br />o samp <br />e su <br />m <br />tta <br />or t <br />e <br />lowing: <br />o <br />? <br />? > t and scheduling Cus od Seal <br />y <br />NELAC <br />A21-A <br />Level IV [3 -dew <br />' o o Comments: Y/N <br />Other ?3 a e <br />EDD/EDT ? Format E a ZjA S&A Schedule Code : Intact <br /> Z s DIS Table # 3 Y/ N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />W = <br />1z <br />Frequency: 5 Signature <br />Y/ N <br />(Name, Location, Date Time Match LAB ID <br /> <br />Interval etc <br />MATRIX Y/N <br />DIS-001A 11/10/10 composite Water ? ? ? ® ? ? ? ? ? ? 01 0 <br />2 ? ? ? ? ? ? ? ? ? ? ? ? ;. <br />a ? ? ? ? ? ? ? ? ? ? ? ? <br />a ? ? ? ? ? ? ? ? ? ? ? ? <br />a ? ? ? ? ? ? ? ? ? ? ? ? <br />s ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />8 ? ? ? ? ? ? ? ? ? ? ? ? V <br />9 ? ? ? ? ? ? ? ? ? ? ? [1 <br />to ? O ? ? ? ? ? ? ? ? ? ? <br /> <br />Custody Relinquished by: Bob Tennant Date/Time: 11/10/10 <br />16:30 <br />Shipped by: <br />5eA <br /> <br />71 <br /> <br />Received by e/Time: t?llO <br /> <br />Record <br />MUST be <br />Relinquished by, Date/Time: <br />Shipped by: Pe <br />Received by: < Date/Time: <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br /> Sample Type # of fractions <br />.V <br />V