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AW 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 />(D <br />Cn <br />0 <br />Company Name: Cotter Corporation Project Name: Schwaruwalder Water Monitoring Program - Dbaharge <br />Tracking No. 3692013_00179889 DATE: _11/10/10 SSTF: S25396 <br />Report Mail Address: Sampler Name if other than Contact: <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 R <br />i <br /> <br />Report Required For POTWNWVfP ? <br />RUSH sample ece <br />pt IQmp <br />,/ f"6 C <br />Other <br />Special Report Formats - ELI must be notified e a <br />V .. o § <br />'T9 >1 <br />g <br />- F submittal for <br />i= additional charges C oler ID(s) <br />prior to sample submittal for the following: m <br />' o t and scheduling <br />' <br />Cust <br />Seal <br />NELAC [I A2LA ? Level IV ? d ? <br />, o S Comments: Y <br />Other <br />EDD/EDT ? Format a 12-1 E S&A Schedule Code : Intact <br /> z s r o, - ?? DIS CODE 02 Y / O <br />Si <br />t <br />SAMPLE a <br />`° a <br />° = <br />? <br />1 <br />Frequency: gna <br />ur <br />Y / <br />IDENTIFICATION Collection Collection .4 C <br />9 N <br />N J <br />m z - Match LAB ID <br />(Name, Location, Date Time a <br />i2 m <br />12 a Y/ it <br />Intervals, etc MATRIX <br />DIS-001A---A 11/10/10 com osite Water ® D ? ? ? ? ? ? ? ? ® ? <br />2 DIS-001A---B 11/11/10 8hr <br />composite water ® ? ? ? ? ? ? ? ? ? ® 6 <br /> <br />_ <br />s DIS-W1A---C 11/12/10 8hr water ® 0 ? ? ? ? ? ? ? ? ® D <br /> composite <br /> ? ? ? ? ? ? ? a ? ? ? ? <br />5 ? ? D ? ? ? ? ? ? D ? ? <br />6 ? ? ? ? ? ? ? ? ? ? ? D <br /> ? a o o ? ? ? ? ? ? ? ? <br />s ? ? ? ? ? ? ? 0 10 ? ? ? <br />s ? ? D ? ? O D ? D ? D ? <br />10 ? ? D ? ? ? ? o ? ? ? ? ?Df/U'S;Y <br /> <br />Custod Relinquished by: Bob Tennant DatefPime: 11/12/10 Shipped by: Received by: Date/Time: <br />y 16:30 <br />Record <br />MUST be Relinquished by: Daterrime: Shipped by: Receved by: Date/Time: <br /> <br />" <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />)le TvDe # of fractions <br />=K