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Company Name: Cotter Corporation <br />Tracking No.5128 09001985 <br />Project Name: Schwartz - - <br />DATE: 5/09/12 SSTF: x26473 -- 526474 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 -1 <br />Contact Name: Randy Whisker <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 - Celt <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215 -1750 <br />Invoice Contact JoAnne Ary <br />Tel: 1-719-275-7413 ext. 209 <br />Fax: -1669 <br />Purchase Order*: <br />ELI Quote t <br />Report Required For POTW/WWTP 0 <br />Other <br />'uonevA'Os ANC As=01.1 <br />*PM ce <br />. <br />addj svldu*g 2 <br />mulqu03 to J4unN <br />ANALYSIS REQUESTED <br />(LvL) punaswn11swioN <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />p additional dunes <br />I . and scheduling <br />R eC P Temp <br />• Co ° C <br />is woo - A4UO - n <br />£0 300D - pwHoggla t - n <br />t03000 PeNosalP I 9ZZ <br />SEE ATTACHED TABLE 1 <br />Coe ID1s) <br />G ~ l <br />Special Report Formats - EtJ must be <br />prior to sample submittal for the foNowii <br />NELAC ❑ A2LA ❑ Level IV 0 <br />Other <br />EDO/EDT ❑ Format <br />Custody Seal <br />Intact <br />Y I N <br />Signature <br />Y / N <br />Match LAB ID <br />Y <br />RUSH Turnaround <br />Comments: <br />S&A Schedule Code : <br />SW CODE 11 <br />Table 1 <br />F ^c 1 . <br />Two e <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />Tun <br />1 SW AWD <br />5/09/12 <br />8:40 <br />Water 1 <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br /># <br />❑ <br />■ <br />■ <br />® <br />■ <br />Code1 <br />2 SW-alk <br />5/09/12 <br />9:00 <br />Water 1 <br />0 <br />❑ <br />0 <br />IN <br />❑ <br />e <br />❑ <br />❑ <br />0 <br />❑ <br />0 <br />0 <br />Code 1 <br />= <br />3 <br />■ <br />■ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />w <br />4 <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />= <br />5 <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />❑❑ <br />>" <br />6 <br />D <br />O <br />❑ <br />❑ <br />D <br />❑ <br />• <br />❑ <br />❑ <br />O <br />■ <br />❑ <br />7 <br />O <br />❑ <br />O <br />0 <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />• <br />0 <br />0 <br />, <br />aGJ7.oro 4 47 <br />m <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />. <br />O <br />❑ <br />■ <br />• <br />❑ <br />9 <br />❑ <br />O <br />❑ <br />0 <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />-1 <br />10 <br />0 <br />0 <br />0 <br />0 • <br />■❑ <br />O <br />D <br />D <br />O <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by Bob Tennant Date/Trme:5109/1218:30 <br />Shipped by: FedEx <br />Shipped by: <br />Received b Date/Tune: <br />Reunquished by Date/Time: <br />Received a "640 4 ,. NO <br />Sample DisposaI: Return to Ghent ❑ Lab Disposal ® <br />ORY 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 />