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v <br />CD <br />CD <br />0 <br />00 <br />Chain of Custody and Analytical Request Record <br />MMINIM <br />PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of 1 <br />Company Name: Cotter Corporation Project Name: Schwartzwaider Water Monitoring Program - <br />Tracking No, 3692013 00180069 DATE: -11105/11 SSTF: S25540-S25546 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick 1-303-642-3893 mine phone <br />PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 213 Bob Tennant 1-719-371-3009-cell <br />Invoice Address: <br />PO Box 1750 Invoice Contact: Kristy Usnick Purchase Order ELI Quote #: <br /> Tel: 1-719-275-7413 ext. 213 <br />Canon City, CO 81215-1750 Fax: 1-719-275-1669 <br /> Notify ELI prior to <br />Report Required For: POTWNWVTP ? RUSH sample Re?mp <br />Other <br />Special Report Formats - ELI must be notified <br /> <br />prior to sample submittal for the followin <br /> <br />?0 <br />c <br />a submittal for <br /> <br />a additional charges I ID(s}o C <br /> <br />C M, <br />51, A <br />g: <br />NELAC ? A2LA ? Level IV ? i m - <br />?', w <br />$ <br />0 <br />m and schedulin <br />Comments: 1 <br />Custody deal <br />Other Q <br />80 U 1 i? Y/ ITV <br />EDD/EDT C) Format . E E S&A Schedule Code : Intact <br /> z ° g SW CODE 11 Y/ N <br />SAMPLE < € x Table 1 Si <br />nat <br />r <br /> <br />' <br />` _ <br />° <br />F g <br />u <br />e <br />IDENTIFICATION Collection Collection a <br />1 z requency/ 1, Y / N <br />(Name, Location, Date Time Z E w Match LAB ID <br />Interval etc MATRIX ai Y / N <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />2 SW ADO1 1105111 9:45 Water 01 131 0 ? ? ? ? p ? ? ® ? Code 1 <br />9 SW BDIS 1105111 10:25 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />SW PL 1/05111 10:35 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />5 SW OS 1105/11 10:45 Water ® ? ? ? ? ? ? ? ? ? ® ? Code l <br />6 SW BOS 1/05/11 11:40 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />z SW GS 1105/11 11:50 Water ® ? ? ? ? ? ? ? ? ? ® ? Code I ?GIU <br />e SW BPL 1/05/11 12:00 Water ® ? ? ? ? ? ? ? ? ? ® ? Code l <br />s ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />Custody <br />rd <br />R Relinquished by: Bob Tennant Date/Time:1/06/11 <br />17:30 <br />Shipped by: <br />Received by: Date/Time: <br />eco <br />MUST be Relinquished by: Date/Time: <br />- Shied b <br /> <br />pp y: <br /> <br />Receive - Date(Time: 9 <br />J0 <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br /> Sam le TvDe # of fractions