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Company Name: Cotter Corporation <br />Tracking No. 5128 0900 1985 <br />Project Name: Schwartz - <br />DATE: 5/8/12 SsTF: x26475 <br />Report Man Address: <br />Cotter Corporation - Canon City MCI <br />PO Box 1750; Canon City, CO 81215 <br />Contact Name: Randy Whisker <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 it <br />ELI Quote*: <br />Report Required For: POTW <br />Other _ <br />'uoomeM <br />AKIAL VaS/svoB t '49 $ wa s <br />snumuc 3 to Actium <br />ANALYSIS REQUESTED <br />(m) PunoJwnl paimoN <br />Notify ELI presto <br />sample <br />submittal br <br />additional charges <br />scheduling <br />ReceipkTemp <br />! • C <br />a•ndde «Z« •t U1004 - Z Men <br />smmddir d • Z awn <br />Special Repo <br />prior to sample <br />NELAC • <br />Other <br />EDD/EDT <br />ELI must be notiflecl <br />for the following: <br />Level <br />❑ Format <br />__a <br />Cooter <br />c f. a !Dm <br />RUSH Turnaround (1 <br />Custody <br />Y / <br />Intact <br />YIN <br />Signature <br />Y / N <br />Match LAB ID <br />Y/N <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />IM <br />Col1ection <br />Time <br />1 MW-00 <br />5 / 8 / 2 0 1 2 <br />14:30 <br />W a r 6 <br />E l <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />0 <br />0 <br />, -. <br />❑ <br />>- <br />2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />0 <br />0 <br />CO <br />3 <br />❑ <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />iu <br />• <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />SO <br />= <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />0 <br />7- <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />1 1 <br />0 <br />0 <br />0 <br />0 <br />0 <br />l '' .. c Y/? <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />a <br />❑ <br />❑ <br />ce <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />o <br />a <br />9 <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />■ <br />• <br />• <br />I <br />❑ <br />❑ <br />D <br />-..i <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Record <br />MUST be <br />si <br />Relinquished by Mal anent Date/Time:5/09/12 16 30 <br />Shipped by: FedEx <br />Received by: Datelrane: <br />Rid by: Dateffime: <br />Shipped by <br />Received by Date/Tune:iv". / /off <br />Sample Disposal: Return to C lent ■ 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 3 of 1 <br />