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Company Name: Cotter Corporation <br />Tracking No 3692013 61650983 <br />Project Name: Schwarlz - - <br />DATE: 9/19112 SSTF: S26643 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 <br />Contact Name: Frank Adamic <br />• " " 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 />Invoice Contact: JoAnne Ary <br />7413 ext 209 <br />Fax: 5 - 1669 <br />Purchase Order #: <br />ELI Quote #: <br />Report Required For. POTW <br />Other <br />Number of Containers <br />Sample Type: <br />-4 v o <br />X �uaeeay �►er vegetation, <br />ANALYSIS REOOESTED <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />< additional charges <br />t and scheduling <br />R T p <br />a C <br />_ _ <br />3000 - pa iontP - n <br />£i moo - PeAlossiP leeoi - n <br />Ra -226 total & dissolved COOE03 <br />Noel <br />ID(s} <br />Special Report Formats - ELI must be <br />prior to sample submittal for the follow <br />NELAC 0 A2tA 0 Level IV 0 <br />Other <br />EDD /EDT 0 Format <br />Custody Seal <br />Y ( 'AI <br />Intact <br />'HA' <br />Signatui' <br />Y <br />Match ID <br />Y/ <br />RUSH Turnaround <br />Comments: <br />SBA Schedule Code : <br />SW CODE I 1 <br />Table 1 <br />Fre�enc 1, <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />' <br />0 <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />1 <br />0 <br />0 <br />0 <br />0 <br />>.. <br />2 SW - BPI. <br />9/19112 <br />8:00 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />❑ <br />® <br />❑ <br />Code 1 <br />Z <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />LU <br />4 <br />❑ <br />D <br />O <br />D <br />O <br />1 3 <br />0 <br />0 <br />0 <br />0 <br />0 <br />rg <br />5 <br />0 .000.000000 <br />, <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />C,tacp4 D -- pE'j <br />0 <br />0 <br />0 <br />. <br />0 <br />0 <br />0 <br />0 <br />_ 0 <br />0 <br />0 <br />• <br />S <br />❑ <br />❑ <br />. <br />s <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />ca <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />.-J <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:9/19/12 16 :30 <br />Shipped by: FedEx <br />Shipped by: <br />Received by: Date/Time: <br />Rer shed by: Date/Time: <br />Received by: )atemme: 3',, -� <br />Sample Disposal: Retum to Client 0 Lab Disposal <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 />