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Company Name: Cotter Corporation <br />Tracking No.5128 0900 1850 <br />Project Name: Schwartz - <br />DATE: 6128/12 SSTF: S26532 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 -17f <br />Contact Name: Frank Adamic <br />Voice: 1-719-275-7413 ext. 204 <br />Sampler Name if other than Contact: <br />1- 303 -642 -3893 mine phone <br />Bob Tennant 1 -7 371- 3009 -cell <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215 -1750 <br />Anne Ary <br />3 ext. 209 <br />Fax: 569 <br />Purchase Order #: <br />- ELI Quote #: <br />Report Required For. POTWPWV <br />Other <br />Number of Containers <br />Same Type: <br />Air, Water oils/Solida, Vegetation, <br />X ilioassay Qther <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 />R eip Temp <br />o C <br />Coo s) <br />I U - dissolved only - CODE #1 <br />�U - total & dissolved - CODE #t3 <br />Ra -226 total & dissolved CODE#3 <br />Special Report <br />prior to sample <br />NELAC IN <br />Other <br />EDD /EDT <br />Formats — ELI must be notified <br />submittal for the following: <br />A2LA ❑ Level IV 0 <br />0 Format <br />Custody Seal <br />Y / <br />Intact <br />Y / M <br />Signature <br />Y / N <br />Match LAB ID <br />Y / N <br />RUSH Turnaround <br />Comments: <br />S&A Schedule Code : <br />SW CODE I 1 <br />Table 1 <br />Frequency' 1, <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />1 <br />• <br />❑ <br />• <br />❑ <br />❑ <br />• <br />• <br />• <br />• <br />❑ <br />❑ <br />• <br />�- <br />2 SW - BPL <br />6428/12 <br />9:30 <br />Water 1 <br />.4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />• <br />❑ <br />Code 1 <br />= <br />0 <br />3 <br />• <br />• <br />a <br />0 <br />0 <br />0 <br />0 <br />• <br />• <br />• <br />. <br />iuI <br />4 <br />❑ <br />• <br />• <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />• <br />• <br />❑ <br />❑ <br />= <br />5 <br />• <br />• <br />• <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />0 <br />0 <br />lx <br />6 <br />• <br />❑ <br />❑ <br />• <br />• <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />0 <br />• <br />C/ c 1J <br />7 <br />0 <br />• <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />0 <br />0 <br />az <br />8 <br />❑ <br />■ <br />■ <br />■ <br />■ <br />❑ <br />■ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />Ca <br />9 <br />. <br />❑ <br />❑ <br />. <br />■ <br />. <br />❑ <br />• <br />. <br />. <br />• <br />❑ <br />10 <br />• <br />0 <br />0 <br />• <br />0 <br />0 <br />• <br />0 0 <br />0 <br />0 <br />Custody <br />Record <br />MUST be <br />Signed <br />._ <br />Relinquished by: Bob Tennant Date/Tme:6/28 /12 16:30 <br />Shipped by: FedEx <br />Shipped by: <br />Received by: Date/Time: <br />Relinquished by: Date/Time: i <br />Received by: 4 . Date/Time: b <br />Sample Disposal: Return to Client 0 Lab Dis ® <br />a mp urn <br />LAB e' f ' �' RY USE ONLY <br />Sample Type # of fractions <br />1 A/3C.>RATOR /ES <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 />I J <br />asS <br />