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Company Name: Cotter Corporation <br />Tracking No. 3692013 6150952 <br />Project Name: Schwartz Am <br />DATE: 9/13/12 SSTF: S26634 & S26635 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 -1750 <br />' <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 />JoAnne Ary <br />13 ext. 209 <br />Fax: 1669 <br />Purchase Order #: <br />ELI Quote*: <br />Report Required For POTWMf WTP El <br />Other <br />MATRIX <br />ANALYSIS REOLIESTED <br />(1Y.L) punaewnj. istwoN <br />Notify ELI prior to <br />sample <br />submittal for <br />< additional Charges <br />i . and scheduling <br />R - <br />is moo - 6tuo pemouip - n <br />pe aaoa - pemossiP mos - n <br />Re-226 total & dissolved CODE#3 <br />SEE ATTACHED TABLE 1 <br />. <br />R.1 <br />Special Report <br />prior to sample <br />NEIAC 0 <br />Other <br />EDD/EDT • <br />Formats – ELI must be notified <br />submittal for the following: <br />AAA ❑ Level IV ❑ <br />Format <br />Y Custod 1 <br />Intact <br />Signatu <br />Y <br />Match L.Ijla <br />Y / 1� <br />RUSH Turnaround <br />Comments: <br />SgA Sct>edule Code : <br />Table 1 CODE , 3 <br />Frequency 4, <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval etc <br />Collection <br />Date <br />Collection <br />Time <br />1 SW FBRG <br />9/13/12 <br />8:30 <br />Water 3 <br />❑ <br />0 <br />0 <br />0 <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />Code 3 <br />)- <br />2 SW ARH <br />EMI <br />8:48 <br />Water 3 <br />❑ <br />® <br />o <br />0 <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />i- <br />❑ <br />Code 3 <br />Z _ <br />3 <br />. <br />❑ <br />• <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />. <br />❑ <br />U.I <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />M <br />❑ <br />❑ <br />• <br />• <br />0 <br />❑ <br />0 <br />❑ <br />❑ <br />0 <br />❑ <br />© <br />}" <br />6 <br />IIIII <br />7 <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />tte <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />0 <br />m <br />G <br />❑ <br />❑ <br />• <br />❑ <br />• <br />❑ <br />❑ <br />. <br />a <br />❑ <br />❑ <br />• <br />.JI <br />10 <br />❑ <br />❑ <br />. <br />❑ <br />. <br />0 <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />Custody <br />Record <br />MUST be <br />Signed <br />Rehnquiehed by: Tennant Date/Time:9/13/12 16 30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Relinquished by: Date Time: <br />Shipped by: <br />Received by - Date/Time: COOL 4 <br />sample Disposal: Return to Client 0 Lab Disposal ® <br />LABORATORY USE ONLY <br />Samp1e 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 />