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Company Name: Cotter Corporation <br />Traddng No 3692013 61651027 <br />Project Name: Schwartz - <br />DATE: 10104/12 SSTF: 826647 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 -175 <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 1 719 - 371 - 3009 - cell <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215 -1750 <br />Anne Ary <br />3 ext. 209 <br />669 <br />Purchase Order #: <br />ELI Quote #: <br />f.1 - 6 <br />Report Required For: PO1WWNTP 0 <br />Other <br />Number at Contslne'e <br />S amPki o <br />X rioter , Yom. <br />ANALYSIS REQUESTED <br />(iY.0 punontuni ptiuxiN <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />P additional charges <br />t and scheduling <br />Receipt Temp <br />3 • ° C <br />US 3003 - A UO Pe^I0$ - t1 <br />dk 3000 - m oss o mai - n <br />£r3Oo3 P■AIOUIP'8 tool 9ZZ-ELI <br />L 'MU <br />GI, ID <br />Special Report Formats — ELI must be notified <br />prior to sample submittal for the following: <br />NELAC ❑ A2LA • Level N 1 <br />Other <br />EDD /EDT 0 Format <br />Custod 1 <br />Y <br />Intact / N <br />Signature <br />Y I N <br />Match LAB ID <br />Y / N <br />Punoaewnj HSAd <br />Comments: <br />SMA O Code : <br />Table I <br />Frequency t, <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Coaedion <br />Date <br />Collection <br />Time <br />2 SWL <br />40!04/12 <br />8:00 <br />Water t <br />® <br />O <br />a <br />❑ <br />■ <br />❑ <br />❑ <br />0 <br />O <br />❑ <br />® <br />❑ <br />Code 1 <br />Z <br />3 <br />• <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />D <br />• <br />W <br />4 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />, 0 1 <br />• <br />n <br />5 <br />O <br />D <br />O <br />■ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />CI <br />❑ <br />6 <br />0 <br />0 <br />0 <br />0 <br />■ <br />O❑ <br />O <br />D <br />D <br />ht�- {.i�c�41 <br />7 <br />• <br />0 <br />• <br />❑ <br />• <br />❑ <br />❑D❑ <br />❑ <br />a <br />8 <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />© <br />❑ <br />■ <br />❑ <br />O <br />❑ <br />❑ <br />co <br />9 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0000 <br />t <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by Bob Tennant DatelTme :10/05112 30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Relhed by Tats <br />Date/a: <br />Shipped by <br />Received by: DaterTirrte:la$ � 11 iC <br />Sample Disposal: Return to Client 0 Lab Disposal <br />e <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 />