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Company Corporation <br />Tracking No.5128 0900 + + <br />Project Name: Schwartz - <br />DATE: 5101/12 SSTF: S26376-- S26383 <br />Report .. <br />Cotter ... _ , . n - Canon City Mill <br />PO Bo + CO : <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 />Invoice Address: <br />' • Box 1750 <br />Canon • + <br />Invoice Contact: Anne Ary <br />3 ext. 209 <br />i69 <br />Purchase Order*: <br />ELI Quote <br />Report Required For. POTWMM <br />Other <br />Number of Containers <br />Sample Type: <br />—I AWSVBO <br />Xl Air, Water lofts/Solids, Yepaa+tkxi• <br />ANALYSIS REQUESTED <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />p additional charges <br />t and scheduling <br />Recutemp <br />o C <br />Cooler ID(s) <br />, <br />C 1 - '� <br />U - dissolved only - CODES 1 <br />£# 9003 • PoNOSS1P V 1.101 n <br />£03003 PeMosalP V10401 9R <br />SEE ATTACHED TABLE 1 <br />Special Report Formats — ELI must be not <br />prior to sample submittal for the following: <br />NELAC 0 A2LA 0 Level IV • <br />Other <br />EDD/EDT • Format <br />Custodyal <br />Y Cpl! <br />intact <br />Y kW <br />Signatu <br />Y <br />Match LAB ID <br />Y / N <br />RUSH Turnaround <br />Comments: <br />&IA Scheme Code : <br />SW CO DE$ 1 <br />Table 1 <br />Frequency' 1, <br />Two coolers <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />1 S W A W D <br />5101/12 <br />11:00 <br />W a t e r 7 <br />D <br />• <br />❑ <br />,- <br />❑ <br />• <br />❑ <br />❑ <br />■ <br />❑ <br />® <br />❑ <br />Tabie1 <br />2 SW-BPL <br />5/01/12 <br />12:15 <br />Water 7 <br />❑ <br />• <br />0 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />'- <br />■ <br />Table 1 <br />.'R' <br />3 <br />❑ <br />D <br />• <br />❑ <br />❑ <br />• <br />❑ <br />D <br />• <br />D <br />• <br />0 <br />iii <br />4 <br />❑ <br />❑ <br />• <br />D <br />■ <br />■ <br />❑ <br />D <br />❑ <br />❑ <br />© <br />= <br />5 <br />0 <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />›- <br />f <br />■ <br />• <br />■ <br />• <br />■ <br />■ <br />■ <br />i <br />CC <br />8 <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />0 <br />• <br />0 <br />0 <br />❑ <br />• <br />❑ <br />lm <br />- <br />_9 <br />D <br />0 <br />• <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />0 <br />• <br />10 <br />❑ <br />❑ <br />D <br />D <br />❑ <br />D <br />❑ <br />❑ <br />• <br />• <br />❑ <br />• <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by Bob Tennant Date/T.me:5/01/12 16:30 <br />Shipped by FedEx <br />Received by: fl — Date/Time:s a _( 71 <br />Relinquished by: Date/Time: <br />Shipped by <br />Received by: Date/Time: <br />Sample Disposal: Return to Client 0 Lab Disposal ►4 <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 />6Z 10 LZ 06ed <br />