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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 />T <br />CD <br />N <br />N <br />O <br />A <br />Company Name: Cotter Corporation Project Name: Scimartiwaider Water Monitoring Program - <br />Tracking No. 3692013 00180052 DATE: _1/05/11 SSTF: S 25539 <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 Receipt Temp <br />Report Required For: POTW1WWTP ? <br />§ RUSH sample <br />C <br />om <br />Other <br />Special Report Formats - ELI must be notified <br />I o I <br />" <br />- <br />v a <br />o <br />T <br />a submittal for <br />P additional charges <br />li <br />h <br />d () <br />Cooler D <br />prior to sample submittal for the followin <br />9 <br />NELAC ? A2LA ? Level IV ? 9 m <br />31 > <br />o <br />yr u <br />n <br />e <br />t and sc <br />Comments: <br />Custody,?eaI <br /> o3 S Y/ <br />Other <br />EDD/EDT C) Format a . r <br />E S8J1 Schedule Code : <br />SW CODE 11 <br />Intac Y / N <br /> z ?a x 9 <br />x Table 1 Signature <br /> <br />SAMPLE Frequency 1, Y / N <br />IDENTIFICATION Collection Collection aim s N a oc Match LAB ID <br />(Name, Location, Date Time Y / N <br />Interval etc MATRIX <br />f SW AWD 1105111 9:00 Water 01 01 0 ® ? ? ? ? ? ? ® ? Table 1 <br /> ? ? ? ? D ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? D D D ? <br /> ? ? ? ? ? ? ? ? ? D ? ? <br /> ? ? ? D ? ? ? ? ? ? ? ? ?r <br /> ? 0 10 ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? a ? ? ? ? ? ? 4,Iw1 J <br /> ? ? ? ? ? ? ? ? ? ? ? D <br />9 ? ? D ? ? ? ? ? ? D ? ? <br />10 ? ? ? ? ? ? ? D ? ? ? ? <br /> <br />d <br />t <br />C Relinquished by: Bob Tennant Date/Time:1/05/11 Shipped by: Rec e y: DaterTime: '? <br />o <br />y <br />us 17:30 <br />Record <br />MUST b Relinquished by: Date/Time: Shipped by: Received by: Datelrime: <br />e <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Type # of fractions