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Company Name: Cotter Corporation <br />Tracking No. 4681 1230 2737 <br />Project Name: Schwartz - <br />DATE: 12/30/11 SSTF: S26173 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 -17 <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 An/ <br />9- 275 -7413 ext. 209 <br />19 -275 -1669 <br />Purchase Order #: <br />ELI Quote #: <br />t -, <br />Report Required For: POTW/W <br />Other <br />papa Ammo K <br />`A 'sQ9oS/sls` min `4v FE <br />t Q <br />swu!quw3 P PAWN M <br />ay.!) punoueuwnl IetwoN <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />additional charges <br />a and scheduling <br />.f <br />Receipt Temp <br />/ - q ° C <br />I Z. 8104U3 - Z 31BV1 <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 n <br />submittal for the following: <br />A2LA ❑ Level IV 0 <br />Format <br />Cool r ID(s) <br />c ceifr <br />RUSH Turnaround (7 <br />Comments: <br />SSA Schedule Code : <br />GW CODE: <br />F ro uen <br />Custody S al <br />Y /I <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 />' <br />• <br />❑ <br />• <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Mine Refill Water <br />12/30/11 <br />12:30 <br />Water 5 <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />• <br />❑ <br />❑ <br />0 <br />❑ <br />0 <br />0 <br />• <br />• <br />• <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />• <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />CI <br />❑ <br />❑ <br />• <br />❑ <br />• <br />❑ <br />• <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />e <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />a <br />❑ <br />❑ <br />❑ <br />• <br />0126 e't <br />e <br />D <br />a <br />❑ <br />0 <br />❑ <br />D <br />• <br />❑ <br />❑ <br />• <br />D <br />1. <br />• <br />0 <br />0 0 <br />0 0 <br />0 0 <br />0 <br />' <br />• <br />❑ <br />Custody <br />Record <br />MUST be <br />Si 9 ned <br />Relinquished by: Bob Tennant Date/Time:12 /30/11 <br />Shi pped by: FedEx <br />Received by: Date/Time: <br />16 : 00 <br />li <br />Ren uished b : Date/Time: <br />q Y <br />Shipped b : <br />PP Y <br />Received b • DaterT _ <br />Y,� �: / Sld 8: end <br />Sample Disposal: Return to Cl ❑ Lab Disposal ►:� <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 />OZ 96ed <br />