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Company Name: Cotter Corporation <br />Tracking No. 4681 1228 3028 <br />Project Name: Schwartz - <br />DATE: _8/17/11 SSTF: S259O9-- S25916 <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 />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215 -1750 <br />JoAnne Ary <br />1413 ext. 209 <br />Fax: -1669 <br />Purchase Order #: <br />ELI Quote #: <br />Report Required For: POT A <br />Other <br />Number of Contains <br />Sample Type - <br />'� AWSVBO <br />73 Air, Water $ods&Solids, vegetation, <br />X §roassay Qther <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />P. additional charges <br />b and scheduling <br />i <br />Receipt Temp <br />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 Ip(s) <br />Special Report <br />prior to sample <br />NELAC • <br />Other <br />EDD /EDT <br />Formats — ELI must be <br />submittal for the follov <br />A2LA • Level <br />❑ Format <br />Custody al <br />Y / <br />Intact <br />Y/N <br />Signature <br />Y / N <br />Match LAB ID <br />Y / N <br />RUSH Turnaround <br />Comments: <br />S&A Schedule Code : <br />SW CODE I1 <br />Table 1 <br />T 1, <br />Two c c000lele rs <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />SW AWD <br />8/17/11 <br />10:00 <br />Water <br />® <br />❑ <br />• <br />❑ <br />• <br />❑ <br />• <br />❑ <br />• <br />• <br />® <br />• <br />Code 1 <br />z SW AOO1 <br />8/17/11 <br />10:10 <br />Water <br />• <br />❑ <br />• <br />❑ <br />• <br />❑ <br />• <br />• <br />❑ <br />A.< <br />• <br />Code 1 <br />SW BDIS <br />8/17/11 <br />10:20 <br />Water <br />0 <br />❑ <br />❑ <br />• <br />❑ <br />• <br />• <br />❑ <br />❑ <br />❑ <br />v:. <br />❑ <br />Code 1 <br />SW PL <br />8/17/11 <br />11:55 <br />Water <br />• <br />❑ <br />• <br />❑ <br />• <br />❑ <br />• <br />❑ <br />• <br />0 <br />❑ <br />Tablel <br />SW OS <br />8/17/11 <br />12:55 <br />Water <br />0 <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />Code 1 <br />6 SW BOS <br />8/17/11 <br />13:05 <br />Water <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />• <br />❑ <br />0 <br />❑ <br />Code 1 <br />SW GS <br />8/17/11 <br />14:40 <br />Water <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />0 <br />• <br />Code 1 <br />,A6)&5"7 <br />s SW BPL <br />8/17/11 <br />14:45 <br />Water <br />0 <br />❑ <br />❑ <br />❑ <br />• <br />• <br />❑ <br />❑ <br />• <br />❑ <br />0 <br />Code 1 <br />0 <br />• <br />0 <br />0 <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />m <br />0 <br />10 <br />0 <br />0 <br />0 <br />• <br />0 0 <br />• <br />0 <br />• <br />0 <br />0 <br />0 <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:8 /18/11 16 30 <br />Sh pped by: <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by' <br />,,.;- .kpatelTime:' -M. // lJ A <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 />