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Company Name: Cotter Corporation <br />Tracking No. 5128 0900 1963 & 1074 <br />Project Name: Schwartz - - <br />DATE: 5/10112 SSTF: S26366 & S26367 &S26368 <br />Report Mall Address: <br />Cotter Corporation - Canon City Mill <br />PO BOX 1750; Canon City, CO 81215 <br />Contact Name: Randy Whicker <br />Vim: 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 />413 ext. 209 <br />1669 <br />Purchase Order #: <br />EU Quote #: <br />Report Required For. POTW <br />Other <br />Number of Contains <br />Sample 'Nat <br />-� AWSVBO <br />Xi Air, Water l fawsol da. yeOetouon, <br />filoassay <br />ANrat.W'Sis REQUESTED <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />R additlonal charges <br />. and scheduling <br />Recei tTemp <br />, C <br />14 3000 - PAP - n <br />£# 3000 - P0No $1P It IPA - n <br />£#3000 PeAlossIP '8 1 9 - ni <br />SEE ATTACHED TABLE 1 <br />I <br />Special Report Formats — ELI must be <br />prior to sample submittal for the follow <br />NELAC ❑ A2LA ❑ Level <br />Other <br />EDD/EDT ❑ Format <br />Custody <br />Y <br />intact <br />Y I N <br />Signature <br />Y / N <br />Match LAB ID <br />YIN <br />nl HSn21 <br />Comments: <br />S&A Schedule Code : <br />SW CODE 13 <br />Table 1 <br />Frequency 4, <br />Two co ocy masers <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />Tin <br />' SW FBRG <br />5110/12 <br />10:10 <br />Water 3 <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />„,---_- <br />❑ <br />-• <br />❑ <br />Code 3 <br />>- <br />2 SW ARH <br />5/10112 <br />9:45 <br />Water 7 <br />0 <br />• <br />❑ <br />:. <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />El <br />❑ <br />Table 1 <br />Z° <br />3 SW LLHG <br />5/10/12 <br />9:35 <br />Water 3 <br />❑ <br />:4 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />• <br />® ❑❑ <br />Code 3 <br />LLI <br />4 <br />❑ <br />• <br />. <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />. <br />❑ <br />❑ <br />❑ <br />= <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />. <br />❑ <br />12 <br />❑ _ <br />• <br />❑ <br />1 ,.. <br />6 <br />❑ <br />o <br />❑ <br />❑ <br />o <br />❑ <br />❑ <br />0 <br />0 <br />• <br />❑ <br />III <br />I- <br />' <br />0 <br />0 <br />0 <br />1 <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />1 : 1 <br />ce <br />8 <br />❑ <br />0 <br />❑ <br />. <br />© <br />❑ <br />❑ <br />` <br />❑ <br />❑ <br />' <br />❑ <br />❑ <br />0t] <br />o <br />9 <br />❑ <br />❑ <br />a <br />❑ <br />• <br />❑ <br />• <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />--J <br />10 <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />0 <br />• <br />• <br />❑ <br />❑ <br />❑ <br />Custody <br />Reco <br />rd MUUST ST be <br />Signed <br />Ti <br />Rermquished by: Bob Tennant Date/me:5/10/12 16 30 <br />Sh pped by: FedEx <br />_ <br />Received by: Date/Time: <br />Relinquished by Date/T me: <br />Shipped by: <br />Received by: y Date/Time: fr.-#. 1 0 <br />Sample Disposal: Retum to Client 0 Lab Disposal Egj <br />LABORATORY USE ONLY <br />Sample Type # of tractions <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 />