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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 />(D <br />N <br />O_ <br />N <br />O <br />Company Name: Cotter Corporation Project Name: Schwartzwalder Water Monitoring Program - <br />Tracking No. 3692013 00180006 DATE: _1119/11 SSTF: S25493-S25500 <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: 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 />t Tem <br />R <br />cei <br /> S <br />l p <br />e <br />p <br />Report Required For: POTWNWVrP C1 RU <br />H samp <br />e , C <br />I <br /> submittal for -- I-) <br />Cooler <br /> <br />o <br />ified <br />Special <br />b <br />. <br />?' <br />w <br />$ <br />additional charges <br />? <br />bQAK <br />P <br />t <br />wn <br />to l ubmittal for the folo <br />sample g: gym w $ and scheduling , <br />l IV El <br />? L <br />F <br />1 i- <br />a <br />' $ m "R Comments: <br />Custody) <br />eve <br />A2LA <br />NELAC <br />- , Q <br />e Y/ <br />Other <br />EDD/EDT ? Format <br />E a U <br />C o < <br />~ e <br />SBA Schedule Code : <br />Intact <br />Y / N <br /> SW CODE 11 <br /> z bl <br />1 <br />T Signature <br />SAMPLE L g < co e <br />a <br />Frequencyt 1 <br />Y / N <br />IDENTIFICATION Collection Collection i z ir , LAB ID <br />Match <br />(Name, Location, Date Time ? ? ? ? Y <br />I N <br />Interval, etc MATRIX <br />SW AWD 1/18/11 14:00 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />2 SW A001 1118/11 14:10 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />9 SW BDIS 1/18/11 15:10 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />4 SW PL 1118/11 15:20 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />5 SW OS 1/18111 15:30 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />e SW BOS 1/19/11 9:50 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />SW GS 1119/11 10:00 Water 10 ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />a SW BPL 1/19/11 10:05 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />a ? ? ? ? ? ? ? ? <br />70 ? ? ? ? ? ? ? ? 9 4 <br /> Relinquished b • Bob Tennant ateJTi e:1/44111 Shipped by: y: Date/Time: <br />ce1v <br />Custody :30 <br />Record <br />b Relinquished by: Date/Time: Shipped by: Received by: Date/Time: kc-uo <br />e <br />MUST <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal 9 LABORATORY USE ONLY <br />Sample Type # of fractions