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Company Name: Cotter Corporation <br />Tracking No 3692013 81650969 <br />Project Name: Schwartz -IN <br />DATE: 9112/12 SSTF: 26633 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 -1 <br />Contact Name: Frank Adamic <br />719- 275 -7413 ext. 204 <br />' Sampler Name if other than Contact: <br />1- 303 - 842 -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 />113 ext. 209 <br />Fax: 1669 <br />r Purchase Order #: <br />ELI Quote t <br />Report Required Far. POTW/V4 <br />Other <br />Number or Containers <br />Sample e <br />ANALYSIS I;'EQUESTED <br />Normal Turnaround (TAT) 1 <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />R additional charges <br />t and scheduling <br />\ •^•• <br />Receipt Temp <br />-4 j( ° C <br />t# 3000 - ocIuo PeMos p - fl <br />U - total d, dissolved - COOS #3 <br />x £13000 PeMOSsiP lz IaMI 9ZZ - e21 <br />L *PM <br />Coole r s) " . <br />Special Report Formats - EI <br />prior to sample submittal for <br />NELAC CI A2LA ❑ <br />Other <br />EDDIEDT 0 Format <br />Custody <br />Y Seal <br />y S <br />Intact <br />Y /87 <br />Signatu <br />Y / <br />Match LA3 ID <br />Y/ <br />RUSH Turnaround <br />Comments: <br />SgA Schedule Code : <br />SW CODE 11 <br />Table 1 <br />Frequency! 1, <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />' <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ - <br />2 SW - BPt. <br />911211 <br />9:30 <br />Water 1 <br />® <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />rgi <br />❑ <br />Cade 1 <br />. <br />= <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o <br />• <br />= <br />4 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />, <br />0 <br />5 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />D <br />a <br />e <br />❑ <br />• <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />•a <br />CorRot4e,t4 <br />7 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />E 3 <br />0 <br />0 <br />0 <br />D <br />0 <br />❑❑ <br />❑ <br />at <br />0 <br />M -•I <br />8 <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />• <br />❑❑ <br />❑ <br />a <br />❑❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑❑ <br />❑ <br />$ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />• <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Ted+ Rent Date/Tiime:9/13/12 16:30 <br />Shipped by: FedEx <br />Shipped by <br />Received by: DatelTime: <br />Relinquished by: Date!►ime: <br />Received by ate/Time: N/L( // . I4 <br />Sample Disposal: Return to Client ❑ Lab Disposal 0 <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 />