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Company Name: Cotter Corporation <br />Tracking No. 3692013 61578416 <br />Project Name: Schwartz - <br />DATE: 5123111 SSTF: 525788-- S25795 <br />Contact Name: Randy Whicker <br />1- 719- 275 -7413 ext. 210 <br />Sampler Name if other than Contact: <br />1- 303 -642 -3893 mine phone <br />Bob Tennant 1- 719 - 371 - 3009 -cell <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81 <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215 -1750 <br />Invoice Contact: JoAnne Ary <br />Tel: 1 - 7413 ext. 209 <br />Fax: 275 - 1669 <br />Purchase Order #: <br />ELI Quote #: <br />Report Required For: PC <br />Other <br />Number of Contains <br />Sample Type: <br />AWSVBO <br />ZJ Air, dater Sod &Solids, Vegetation, <br />X Bioassay Other <br />Normal Tumaround (TAT) <br />Notify Ell prior to <br />RUSH sample <br />submittal for <br />additional charges <br />t and scheduling <br />Recut Jemp <br />�j t m C <br />U - dissolved only - CODE #1 <br />U - total & dissolved - CODE #3 <br />Ra -226 total & dissolved CODE#3 <br />SEE ATTACHED TABLE 1 <br />Cooler ID(s) <br />C -l; <br />Custody ,S0 <br />Y / <br />Intact <br />Y I N <br />Signature <br />Y / N <br />Match LAB ID <br />Y / N <br />Special Report Formats — ELI mu <br />prior to sample submittal for the f� <br />NELAC ❑ A2LA ❑ Level IV 0 <br />Other <br />EDD /EDT ❑ Format <br />RUSH Turnaround <br />Comments: <br />SBA Schedule Code : <br />SW CODE 11 <br />Table 1 <br />T o coo er 1, <br />Twwo cooler 1, <br />- <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />' SW AWD <br />5/23/11 <br />10:25 <br />Water <br />0 <br />❑ <br />❑ <br />• <br />D <br />❑ <br />❑ <br />• <br />❑ <br />• <br />El <br />• <br />Code 1 <br />SW AO01 <br />5/23/11 <br />10:35 <br />Water <br />0 <br />❑ <br />❑ <br />• <br />• <br />• <br />• <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />Code 1 <br />SW BDIS <br />5/23/11 <br />12:10 <br />Water <br />® <br />• <br />• <br />❑ <br />❑ <br />• <br />❑ <br />• <br />❑ <br />• <br />ci <br />❑ <br />Code 1 <br />SW PL <br />5/23/11 <br />12:35 <br />Water <br />® <br />❑ <br />• <br />❑ <br />0 <br />• <br />❑ <br />❑ <br />• <br />❑ <br />0 <br />0 <br />Code 1 <br />SW OS <br />5/23111 <br />13:05 <br />Water <br />® <br />• <br />0 <br />• <br />• <br />❑ <br />• <br />• <br />❑ <br />❑ <br />►'- <br />• <br />Code 1 <br />s SW BOS <br />5/23/11 <br />13:40 <br />Water <br />® <br />❑ <br />❑ <br />• <br />• <br />• <br />❑ <br />• <br />• <br />❑ <br />■ e <br />• <br />Code 1 <br />, <br />SW GS <br />5/23/11 <br />14:15 <br />Water <br />® <br />• <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />• <br />• <br />❑ <br />o <br />❑ <br />Code 1 <br />'7 /7Osdg3 <br />8 SW BPL <br />5/23/11 <br />14:40 <br />Water <br />o <br />❑ <br />■ <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />r ■ <br />❑ <br />:.o <br />❑ <br />Code 1 <br />, /. <br />9 <br />• <br />• <br />❑ <br />■ <br />• <br />• <br />❑ <br />❑ <br />❑ <br />. <br />• <br />❑ <br />to <br />• <br />D <br />• <br />• <br />❑ <br />❑ <br />❑ <br />• <br />D <br />■ <br />❑ <br />❑ <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bo Tennant Date/Time:5 /24/11 16:30 <br />q Y <br />Sh pped by: <br />pp Y <br />Shipped by: <br />Re ceived b Date/Time S - if <br />Y t /00C. <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Sample Disposal: Retum to Client • Lab Disposal 0 <br />LABORATORY USE ONLY <br />Sample Type # of fractions ^, <br />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 />