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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 />(D <br />co <br />0 <br />N <br />O <br />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No. _3692013 00180274 DATE: _3104111 SSTF: S25660 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Randy Whicker 1-303-642-3893 mine phone <br />PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 210 Bob Tennant 1-719-371-3009-cell <br />Invoice Address: Invoice Contact: JoAnne Ary Purchase Order #: ELI Quote #: <br />PO Box 1750 Tel: 1-719-275-7413 ext. 209 <br />Canon City, CO 81215-1750 Fax: 1-719-275-1669 <br /> Notify ELI prior to <br />Report Required For: POTWANWTP ? RUSH sample Receipt, <br />Other submittal for l Kg- <br />Special Report Formats - ELI must be notified g <br />o 3 a additional charges Cooler ID(s) <br />prior to sample submittal for the following: t <br />I'M <br />1 w and schedulin g <br />CAL <br />NELAC ? A2LA ? Level IV ? 2 <br />0 <br />610'a L e ° Comments: Custody Seal <br />Other <br /> <br />EDD/EDT [I Format 31 - <br />I'l < g <br /> <br />a N <br /># <br /> <br />5 <br />SBA Schedule Code : Y /,Z)) <br /> <br />Intact <br /> Z E GW CODE: Y/ N <br /> f ,? 8 > <br />Signature <br />SAMPLE <br />aO <br />N N a <br />Y/N <br />IDENTIFICATION Collection Collection a <br />uen <br />Fr Match LAB ID <br />(Name, Location, Date Time m m ? Y ! N <br />Interval, etc) MATRIX 'a- ~ <br />Sump--8 3!04!11 11:35 Water ® O ? ? ? ? ? ? ? ? ® O Table 2 <br />2 0 10 ? ? ? ? ? ? ? ? ? ? <br />3 ? ? ? ? ? a ? ? ? ? ? ? <br />4 ? a ? ? ? ? a ? ? ? ? a <br />s ? ? ? ? ? a ? ? ? ? ? a <br />6 ? ? ? ? ? ? ? a ? ? a ? <br />7 a ? ? ? ? ? ? ? O ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />9 <br /> ? ? ? ? ? ? ? ? a ? ? ? <br /> 9 <br /> a ? ? ? ? ? ? ? ? ? ? ? <br /> 10 <br /> Relinquished by: Bob Tennant Date/Time:3/04/11 Shipped by: Date/Time:31'lk t <br /> Custody 14:30 <br /> Record <br />ST b Relinquished by: Date/Time: Shipped by: Received by: Daterrime: <br /> MU <br />e <br />Signed <br />Sample Disposal: Retum to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions <br />ro