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Company Name: Cotter Corporation <br />Tracking No. 3692013 61576023 <br />Project Name: Schwartz - <br />DATE: 4114/11 SSTF: S25710 - -- S25712 <br />Report Mail Address: <br />Cotter Corporation - Canon City MIII <br />PO Box 1750; Canon City, COs <br />Contact Name: Randy Whicker <br />1- 719 -275 -7413 ext. 210 <br />_ <br />Sampler Name if other than Contact: <br />1- 303 - 642 -3893 mine phone <br />Bob Tennant 1 -719- 371 - 3009 -cell <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215 -1750 <br />Invoice Contact: JoAnne Ary <br />275 -7413 ext. 209 <br />Fax: 9 275 - 1669 <br />Purchase Order #: <br />ELI Quote #: <br />Report Required For. P <br />Other <br />Number of Contains <br />Sample Type: <br />AWSVBO <br />Air, Water Soils/Solids. Yepetation. <br />X @ioassay Otter <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />p additional charges <br />t and scheduling <br />Receipt Temp <br />ac <br />U - dissolved only - CODE #1 <br />U - total & dissolved - CODE #3 <br />L cioo POMoss!P V leeo>; 9ZL-e21 <br />i SEE ATTACHED TABLE 1 <br />Co' ,=r I (s) <br />Special Report Formats — ELI must be notified <br />prior to sample submittal for the <br />Cu: , eaI <br />Y Cl■ <br />Intact <br />Y / N <br />Signature <br />Y / N <br />Match LAB ID <br />Y/N <br />NELAC ❑ A2LA ❑ Level _l I. 0 <br />Other <br />EDD /EDT • Format <br />RUSH Turnaround <br />Comments: <br />S&A Schedule Code : <br />SW CODE 13 <br />Table 1 <br />Frequency 4, <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />1 SW FBRG <br />4/13/11 <br />12:30 <br />Water <br />0 <br />■ <br />■ <br />0 <br />❑ <br />0 <br />■ <br />■ <br />0 <br />❑ <br />0 <br />■ <br />Table 1 <br />2 SW ARH <br />4/13/11 <br />12:50 <br />Water <br />❑ <br />0 <br />® <br />❑ <br />❑ <br />❑ <br />• <br />• <br />❑ <br />• <br />® <br />• <br />Code 3 <br />3 SW LLHG <br />4/13/11 <br />13:10 <br />Water <br />• <br />® <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />❑ <br />❑ <br />0 <br />0 <br />Code 3 <br />4 <br />0 <br />• <br />0 <br />0 <br />• <br />• <br />0 <br />• <br />0 <br />• <br />. <br />❑ <br />5 <br />0 <br />0 <br />0 <br />0 <br />• <br />0 <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />6 <br />• <br />• <br />0 <br />0 <br />• <br />❑ <br />• <br />0 <br />0 <br />• <br />• <br />• <br />. <br />7 <br />• <br />• <br />• <br />❑ <br />0 <br />0 <br />❑ <br />• <br />o <br />❑ <br />• <br />. <br />6 <br />0 <br />0 <br />❑ <br />• <br />❑ <br />❑ <br />• <br />• <br />• <br />❑ <br />0 <br />0 <br />p32 <br />9 <br />❑ <br />0 <br />• <br />❑ <br />• <br />D <br />❑ <br />• <br />• <br />❑ <br />• <br />• <br />10 <br />❑ <br />• <br />• <br />• <br />❑ <br />0 <br />0 <br />❑ <br />• <br />• <br />D <br />D <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:4 /14/11 15 30 <br />Sh pped by: <br />CX <br />Rece ed at�ITime: fjsill q <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Shipped by: <br />Sample Disposal: Return 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 />0£ Jo 9Z e6ed <br />