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Company Name: Cotter Corporation <br />Tracking No 3692013 61650938 <br />Project Name: Schwartz -NB <br />DATE: 9/05/12 SSTF: S26562 <br />Report Mai Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 -17 <br />Contact Name: Frank Adamic <br />Voice: 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: 669 <br />Purchase Order t <br />ELI Quote it <br />e7‘ y <br />Report Required For. po 0 <br />Other <br />Number of Containers <br />Sample Type: <br />AWSVBO <br />?C tor, Rolle/Solids, Yom <br />ANA...YSl= RcoL _ MI C <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />p additional charges <br />t. and scheduling <br />Receipt Temp <br />.....S,24° C <br />Coder ID(s) <br />G t ' Q"l �` <br />l# WOO - Auo pBNOip - f 1 <br />U - total & dissolved - CODE 03 <br />Ra-228 total & dissolved CODE03 <br />I. Wiwi <br />Special Report Formats — ELI must be n+ <br />. prior to sample submittal for the following <br />NELAC ❑ A2LA ❑ Level IV <br />Other <br />EDD /EDT ❑ Format <br />• <br />Custod <br />Intact <br />/ N <br />Signature <br />Y! N <br />Match LAB ID <br />Y/N <br />I RUSH Turnaround <br />Comments: <br />S v Schedule Code : <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 />0 <br />0 <br />0 <br />0 <br />0 <br />a <br />0 <br />0 <br />1 : 1 <br />1 1 1 <br />0 <br />0 � <br />2 s l - 8 P L <br />9/05/12 <br />9:30 <br />W a t e r 1 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />®❑ <br />Code 1 <br />3 <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />D <br />❑ <br />0 <br />4 <br />a <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />' D <br />CI <br />5 <br />D❑ <br />D <br />D <br />D❑ <br />D❑ <br />D <br />D <br />D❑ <br />CIact3 of 40 <br />6 <br />❑ <br />• <br />❑ <br />❑ <br />C] <br />❑ <br />■ <br />❑ <br />D <br />D <br />D <br />❑ <br />1.-,-. <br />7 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />tx <br />8 <br />❑ <br />• <br />❑ <br />0 <br />D <br />❑ <br />❑ <br />❑ <br />D <br />D <br />❑ <br />❑ <br />Ca <br />9 <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />D <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />vtt <br />.s <br />10 <br />D <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:9/05/12 16:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Shipped by: <br />l <br />Received by: 1°6G.�, Date/Time: 7 6, 1 �/ I p <br />Sample Disposal: Return to Client Q 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 />8Z 40 LZ 96ed <br />