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Company Name: Cotter Corporation <br />Tracking No. _3692013 61578675 <br />Project 'Name: Schwartz - <br />DATE: 6130/11 SSTF: 525825 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 812 <br />Contact Name: Randy Whicker <br />e: 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 />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215 -1750 <br />Invoice Contact: JoAnne Ary <br />1- 719 -275 -7413 ext. 209 <br />Fax: I 719 - 275 - 1669 <br />Purchase Order #: <br />ELI Quote #: <br />Report Required For: POTYWWWTP D <br />Other <br />M Number of Containers 1 <br />D Sample Type: <br />-I AWSVBO <br />Air, Water Soils/Solids. Vegetation, i <br />X Bioassay Other <br />Normal Turnaround (TAT) J <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />additional charges <br />a and scheduling <br />- =rQi •t Temp <br />e ° C <br />' !" i <br />/i,V, <br />TABLE 2 - Footnote "2" applies <br />TABLE 2 - Footnote "1" applies <br />Special Report <br />prior to sample <br />NELAC ❑ <br />Other <br />EDD /EDT ■ <br />Formats — ELI must be notified <br />submittal for the following: <br />A2LA 0 Level IV <br />Format <br />RUSH Turnaround (1 <br />Comments: <br />S&A Schedule Code : <br />GW CODE: <br />Fr ue <br />Custody Seal <br />Y /0 <br />Intact <br />Y / N <br />Signature <br />Y / N <br />Match LAB ID <br />Y ! N <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />1 MW -12 <br />8/30/11 <br />14:20 <br />Water <br />® <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />• <br />❑ <br />• <br />❑ <br />0 <br />❑ <br />Table 2 <br />z <br />0 <br />0 <br />0 0 <br />• • <br />• <br />• <br />0 0 <br />0 <br />0 <br />s <br />. <br />. <br />•0 <br />❑ ■ <br />0 <br />. <br />■ . <br />❑ <br />❑ <br />• <br />s <br />0 0 <br />0 0 <br />0 <br />0 <br />• • <br />0 <br />0 <br />e <br />• <br />. <br />0 0 <br />0 . <br />0 <br />0 <br />0 2 <br />❑ <br />❑ <br />e <br />• <br />❑ <br />❑ • <br />. ❑ <br />❑ <br />. <br />. . <br />❑ <br />. <br />• <br />• <br />• • <br />0 • <br />0 <br />• <br />0 0 <br />0 <br />0 <br />B <br />■ <br />❑ <br />❑ ■ <br />■ ❑ <br />❑ <br />■ <br />❑ ■ <br />❑ <br />❑ <br />• <br />• <br />■ ■ <br />❑ ❑ <br />❑ <br />❑ <br />❑ ❑ <br />• <br />• <br />PA4Vd <br />10 <br />0 <br />• <br />0 0 <br />0 • <br />• <br />0 <br />• 0 <br />• <br />0 <br />Custody <br />Recorde <br />Signed <br />Relinquished by: Bob Tennant Date/Time:7 /01/11 13 30 <br />Shipped by: <br />Shipped by .. 4 4-( <br />Receiv- • by: Date/Time: <br />- ' "'i /ffiz Date/Time: j <br />Relinquished by: Date/Time: <br />Sample Disposal: Retum to Client ❑ Lab Disposal CA <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 />