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Company Name: Cotter Corporation <br />Tracking No. 3692013 61588935 <br />Project Name: Schwartz - <br />DATE: _8/10/11 SSTF: 525161— S25163 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 <br />Contact Name: Randy Whicker <br />- 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 />JoAnne Ary <br />Tel: 1-719-275-7413 ext. 209 <br />Fax: -1669 <br />Purchase Order #: <br />ELI Quote #: <br />Report Required For: POT' <br />Other <br />C Number of Contains <br />D Sample Type: <br />—I AWSVBO <br />Xli Air, Water Boits/Solids, Vegetation. <br />X Bioassay Other <br />Normal Tumaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />F additional charges <br />. and scheduling <br />Receiptemp <br />r� a C <br />U - dissolved only - CODE #1 <br />U - total & dissolved - CODE #3 <br />Ra -226 total & dissolved CODE#3 <br />SEE ATTACHED TABLE 1 <br />Cooler ID(s) <br />Special Report <br />prior to sample <br />NELAC • <br />Other <br />EDD /EDT <br />Formats — ELI must be <br />submittal for the following: <br />A2LA ❑ Level <br />❑ Format <br />Custody al <br />Y / 1 <br />Intact <br />Y I N <br />Signature <br />YIN <br />Match LAB ID <br />YIN <br />RUSH Turnaround <br />Comments: <br />S&A Schedule Code : <br />SW CODE 13 <br />Table 1 <br />Frequency' 4, <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />' SW FBRG <br />8/10/11 <br />12:45 <br />Water <br />• <br />® <br />,- <br />❑ <br />• <br />❑ <br />• <br />❑ <br />❑ <br />• <br />t74 <br />❑ <br />Code 3 <br />z SW ARM <br />8/10/11 <br />13:00 <br />Water <br />• <br />❑ <br />• <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o- <br />❑ <br />Table 1 <br />SW LLHG <br />8/10/11 <br />13:25 <br />Water <br />• <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />Code 3 <br />❑ <br />• <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />• <br />■ <br />❑ <br />❑ <br />0 <br />• <br />0 <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />s <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 />• <br />❑ <br />• <br />• <br />❑ <br />❑ <br />, ❑ <br />❑ <br />9 <br />• <br />❑ <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />• <br />CN w'Kr k <br />10 <br />0 <br />i • <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />, <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:8 /10/11 17 30 <br />Sh pped by: <br />Shipped by: <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Received by: , Date/Time: got/ /1‘,3 <br />Sample Disposal: Return to Client ❑ Lab Disposal 0 <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 />fed jJ <br />6Z lo 9Z abed <br />