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Company Name: Cotter Corporation <br />Tracking No. 3692013 61629668 <br />Project Name: Schwartz - <br />DATE: 12/14/11 SSTF: S26167- -- S26168 <br />Report Mall Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 -1' <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 />9 - 275 - 7413 ext. 209 <br />Fax: 19 275 - 1669 <br />Purchase Order #: <br />ELI Quote #: <br />r - 6 <br />Report Required For: POTVV/WWTP <br />Other <br />Number or containers <br />Sample Type: <br />--4 AWSVBO <br />� . Yepetation, <br />1 (idl) PunWnl IeWuoN <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />additional charges <br />a and scheduling <br />Receipt zemp <br />2, Co o c/ <br />wild& 2,. J - Z 318x1 <br />goildde ALA •0u4004 - Z 318r►1 <br />Special Report Formats - ELI must be Wined <br />prior to sample submittal for the following: <br />NELAC ❑ A2LA • Level IV <br />Other <br />EDD/EDT ❑ Format <br />• <br />Cooler ID(s) <br />c. b en <br />RUSH Turnaround (T <br />Comments: <br />S&A Schedule Code : <br />OW CODE: <br />1611.1 <br />Custody Seal <br />Y /C <br />intact <br />Y / N <br />Signature <br />Y 1 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 SUMP -8 <br />12/14111 <br />12:30 <br />W a t e r 6 <br />RI <br />D <br />O <br />D <br />O <br />• <br />❑ <br />❑ <br />D <br />D <br />I ® <br />❑ <br />2 SUMP -1 <br />12/14/11 <br />13:55 <br />Water 6 <br />® <br />• <br />• <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />0 <br />❑ <br />3 <br />❑ <br />❑ <br />• <br />• <br />• <br />❑ <br />• <br />❑ <br />❑ <br />D <br />• <br />- <br />❑ <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />• <br />❑ <br />S <br />• <br />D <br />❑ <br />• <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />• <br />❑ <br />D <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />D <br />D <br />• <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />D <br />/j <br />'G <br />8 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />9 <br />❑ <br />■ <br />• <br />■ <br />❑ <br />❑ <br />■ <br />D <br />❑ <br />■ <br />❑ <br />• <br />10 <br />0 <br />0 0 <br />0 0 <br />0 0 <br />• <br />0 <br />• <br />D <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:12 /15/11 <br />Shipped by: FedEx <br />pped y' <br />Received by: Date/Time: <br />y' <br />16:00 <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received b )K.G 5 Date/Time: /J-11.1r d): <br />Sample Disposal: Return to Client 1111 ® <br />Lab Disposal <br />LABORATORY USE ONLY <br />Sample <br />e 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 />