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Company Name: Cotter Corporation <br />Tracking No.3692013 61634488 <br />Project Name: Schwartz - <br />DATE: 4/11/12 SSTF: S26436 & S26442 & S26443 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81: <br />Contact Name: Randy Whicker - <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 />>75 - 7413 ext. 209 <br />Fax: 275 - 1669 <br />Purchase Order #: <br />ELI Quote #: <br />Report Required For PO' <br />Other <br />C Number of Containers <br />Sample Type. <br />— 1 AWSVBO <br />Air, Water $oils/Solids, yepetatIon, <br />X Bioassay Qther <br />ANAL, Y5t S RE QU 3v <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />a additional charges <br />. and scheduling <br />Re p#,jemp <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 />C olgr.ID(s <br />' <br />Special Report Formats - ELI must <br />prior to sample submittal for the fo <br />NELAC ❑ A2LA ❑ Li <br />Other <br />EDD /EDT 0 Format <br />Custody,Seal <br />Y <br />Intact <br />YIN <br />Signature <br />Y / N <br />Match LAB ID <br />Y / N <br />RUSH Turnaround <br />Comments: <br />S&A Schedule Code : <br />SWCODEU1 <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 SW AWD <br />4/11/12 <br />12:15 <br />Water 1 <br />® <br />❑ <br />• <br />❑ <br />• <br />❑ <br />❑ <br />• <br />❑ <br />• <br />0 <br />❑ <br />Code 1 <br />❑ <br />❑ <br />• <br />❑ <br />• <br />❑ <br />• <br />❑ <br />❑ <br />• <br />❑ <br />• <br />• <br />❑ <br />• <br />• <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />ua <br />• <br />• <br />0 <br />• <br />• <br />0 <br />0 <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />E 1 <br />• <br />0 <br />0 <br />0 <br />• <br />0 <br />0 <br />>" <br />• <br />0 <br />0 <br />• <br />0 <br />0 <br />• <br />• <br />• <br />• <br />❑ <br />• <br />SW GS <br />4/05/12 <br />14:45 <br />Water 1 <br />0 <br />• <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />• <br />❑ <br />❑ <br />0 <br />Code 1 <br />Code 1 <br />o <br />a SW BPL <br />4/05/12 <br />14:00 <br />Water 1 <br />0 <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />0 <br />0 <br />. <br />u <br />• <br />0 <br />• <br />O <br />• <br />0 <br />0 <br />0 <br />_ <br />10 <br />0 <br />• <br />0 <br />• <br />• <br />• <br />0 0 <br />1 D <br />• <br />0 <br />0 <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:4 /12112 16:30 <br />Shipped by: FedEx <br />Shipped by: <br />Received b 0. 4,p9ate/Time:;4.I 3. j o t <br />Relinquished by: Date/Time: <br />Received by: Date/Time: <br />Sample Disposal: Return to Client 0 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 />