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Company Name: Cotter Corporation <br />Tracking No. _3692013 61576064 <br />Project Name: Schwartz - <br />DATE: 4/20/11 SSTF: 525759 & 25760 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81 <br />Contact Name: Randy Whicker <br />Voice: 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 />c: 1 719 - 275 - 1669 <br />Purchase Order #: <br />ELI Quote #: <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />additional charges <br />a and scheduling <br />Rec 'pe t 7 mp <br />� o C <br />Report Required For: PC <br />Other <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 • Level IV <br />Format <br />Number of Container <br />Sample <br />— AWSVBO <br />Air, Water Soils /Solids, Vege <br />Bioassay Other <br />Cooler ID (s) <br />∎ f -- <br />RUSH Turnaround (I <br />Comments: <br />S&A Schedule Code : <br />GW CODE: <br />Fr uenc : <br />Custody eaI <br />Y / � <br />Intact <br />Y / N <br />Signature <br />Y / N <br />Match LAB ID <br />/ N <br />rt AMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />MW -1 <br />4/20/11 <br />13:10 <br />Water <br />►= <br />• <br />❑ <br />❑ <br />❑ <br />• <br />• <br />❑ <br />• <br />• <br />® <br />❑ <br />Table 2 <br />z MW -0 <br />4/20/11 <br />10:15 <br />Water <br />® <br />. <br />❑ <br />0 <br />❑ <br />0 <br />❑ <br />. <br />❑ <br />0 <br />❑ <br />. <br />• <br />. <br />• <br />. <br />❑ <br />. <br />• <br />. <br />® <br />❑ <br />❑ <br />■ ' <br />Table 2 <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />1 1 1 <br />• <br />D <br />• <br />0 <br />• <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />0 <br />0 <br />1 1 1 <br />E ] <br />0 <br />. <br />❑ <br />. <br />❑ <br />❑ <br />. <br />❑ <br />. <br />❑ <br />. <br />L. <br />❑ <br />G logGYr7' <br />• <br />0 <br />• <br />0 <br />0 <br />• <br />• <br />0 <br />0 <br />0 <br />• <br />• <br />e <br />• <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />• <br />• <br />0 <br />❑ <br />9 <br />• <br />• <br />0 <br />• <br />0 <br />0 <br />0 <br />• <br />0 <br />C 1 <br />❑ <br />❑ <br />10 <br />• <br />• <br />• <br />❑ <br />❑ <br />■ <br />❑ <br />• <br />• <br />❑ <br />• <br />❑ <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:4 /20/11 15 30 <br />Shipped by: X <br />Shipped by: <br />Received b � to ime: .-I /11 9,5 <br />R elinquished by: Date/Time: <br />Received by: DatelTime: <br />Sample Disposal: Return to Client 0 Lab Disposal CI <br />LABORA ORY 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 />