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N <br />0 <br />w <br />-;A <br />LA00 <br />Chain of Custody and Analytical Request Record <br />PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. <br />Page 1 of 1 <br />Company Name: Cotter Corporation Project Name: Schwartzwalder Water Monitoring Program - <br />Tracking No. 3692013 00180076 DATE: _1/13/11 SSTF: S25440-S25447 <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 /> <br />Report Required For: POTWNVWTP ? <br />RUSH sample Rece <br />t emp <br />T <br /> <br />Other <br />Special Report Formats - ELI must be notified <br /> <br /> <br />9 ° <br />'? <br /> <br />a <br /> <br />Q <br />submittal for <br />F additional charges a C <br /> <br />r ID(s) <br />prior to sample submittal for the following: m <br />8 '. w <br />° <br />° 0 <br />g and schedulin <br />NELAC [I A2LA [I Level IV El <br />3 <br />8 <br />e <br />Comments: Custod Sal <br />; <br />Other ° Y / <br />I <br />t <br />EDD/EDT ? Format SBA Schedule Code : n <br />act <br /> S W CODE I I Y I N <br />SAMPLE I € x Table 1 <br />Frequency 1 Signature <br />YIN <br />IDENTIFICATION Collection Collection , <br />(Name, Location, Date Time <br /> <br />2 W <br /> <br />N <br />Match LAB ID <br />Interval etc MATRIX a U Y I N <br />' SW AWD 1/11/11 12:45 Water ® ? ? ? ? ? ? ? ? ? N ? Code 1 <br />2 SW A001 1/11/11 12:20 Water ® ? ? ? ? ? ? ? ? ? 9 ? Code 1 <br />a SW BOIS 1/11/11 12:30 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />4 SW PL 1/12111 13:55 Water N, 01 0 ? ? ? ? ? ? ? ® ? Code 1 <br />5 SW OS 1/12/11 14:05 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />6 SW BOS 1/12111 14:15 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />SW GS 1/13/11 9:30 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />e SW BPL 1113/11 9:40 Water ? ? ? ® ? ? ? ? ? ? ® ? Table 1 <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />Custody Relinquished by: Bob Tennant Date/Time:1113/11 <br />12:30 <br />Shipped by: <br />Received by: Date/Time: <br />Record <br />MUST be <br />Relinquished by: Datefrime: <br />Shipped by: ` t`/ (11. <br />Receiv - f la: aterTime:? k ; ? . % <br /> <br /> <br />Signed <br /> <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY <br /> <br />USE <br />ONLY' <br /> r <br />Sample Type # of fractions