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Company Nan q;Cotter Corporation <br />Tracking No. x'681 1228 2960 <br />Project Name: Schwartz - <br />DATE: 9/08/11 SSTF: S25937 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 -1750 <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 />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215 -1750 <br />Invoice Contact: JoAnne Ary <br />719- 275 -7413 ext. 209 <br />Fax: •719 -275 -1669 <br />Purchase Order #: <br />ELI Quote #: <br />Report Required For: POTWNVWTP ❑ <br />Other <br />8'->M <br />tioa <br />x 1 <br />I <br />�� <br />MATRIX <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />additional charges <br />a and scheduling <br />f f fk <br />Receipt Temp <br />7.1 ° C <br />1 <br />seydde 2. aWillood - Z 31UV.L <br />send .4„ 040L400A - Z 318V1 <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 0 <br />❑ Format <br />Cooler ID(s) <br />(/ e,t <br />RUSH Turnaround (1 <br />Comments: <br />SBA Schedule Code : <br />GW CODE: <br />Fri a : <br />Custody eal <br />Y SC <br />Intact <br />Y / N <br />Signature <br />YIN <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 />SUMP - -10 <br />9/08/11 <br />07:45 <br />Water <br />® <br />❑ <br />• ■ <br />❑ <br />❑ <br />• ■ <br />❑ <br />❑ <br />❑ <br />a <br />■ <br />® <br />15 DAY TURN <br />AROUND <br />• <br />• <br />0 <br />❑ <br />in <br />❑ <br />• <br />❑ <br />. <br />❑ <br />+_ <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />0 <br />0 <br />• <br />• <br />❑ <br />0 <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />© <br />• <br />• <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />• <br />a <br />❑ <br />❑ <br />• <br />• <br />❑ <br />❑ <br />a <br />• <br />• <br />• <br />• <br />. <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />• <br />❑ <br />❑ <br />❑ <br />9 <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />10 <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />• <br />❑ <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:9 /08/11 10 30 <br />Sh pped by: <br />Shipped by: <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Received by4.4....Date/Time: I T, i t Tr, ; <br />Sample Disposal: Return to Client ❑ Lab Disposal CI ,Sample <br />LABORATORY USE ONLY <br />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 />OZ Jo 81. abed <br />