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Company Name: Cotter Corporation <br />Tracking No. 3692013 61702811 <br />Project Name: Schwartz - <br />DATE: 8/31/12 SSTF: S26629 <br />Report Mail Address: <br />Cotter Corporation - Canon City MW <br />PO Box 1750; Canon City, CO 81215 -1 <br />Contact Name: Frank Adamic <br />e: 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 />; 1- 719 - 275 -7413 ext. 209 <br />: 1-719-275-1669 <br />Purchase Order #: <br />ELI Quote #: <br />Report Required For: POTWA <br />Other <br />I f Number of Containers <br />Semple Type: <br />—I AWSVBO <br />XI Ak, warm Bolts/Solids, Y�I�. <br />X Bioassay Qther <br />ANALYSIS REQUESTED <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />additional charges <br />< <br />g. and scheduling <br />Re <br />_ Temp <br />. i p <br />/(,[ <br />$.III ..Z.. 400u4004 - L 3161111 <br />° <br />Cools D(s <br />� EtYI �t <br />Special Report Formats— Eft must be notified <br />prior to sample submittal for the following: <br />NELAC 0 A2LA ❑ Level 1 <br />Other <br />EDD/EDT ❑ Format <br />Custody I <br />Y / <br />Intact <br />Y <br />Signature <br />Y /6 <br />Match LAB ID <br />Y / N <br />RUSH Turnaround i <br />Comments: <br />SU Schedule Code : <br />GW CODE: <br />Fiji= <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Co Ti llection <br />me <br />i <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />1 1 1 <br />0 <br />0 <br />2 MW - 9 <br />8/31/12 <br />9:35 <br />Water 6 <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />b <br />3 <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />• <br />❑ <br />Ili <br />' <br />❑ <br />❑ <br />© <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />❑ <br />■ <br />❑ <br />❑ <br />= <br />s <br />D <br />❑ <br />❑ <br />• <br />❑ <br />• <br />❑ <br />❑ <br />© <br />❑ <br />❑ <br />❑ <br />e <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />e4ePat1 <br />7 <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />Q r 1 7o, a.r <br />8 <br />❑ <br />■ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />■ <br />r Received by Date/Time: <br />Received by: . Date/Time: Q/'(!t Z bz <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: ob Tennant DatetTirne:8/31 /12 16:30 <br />Shipped by: FedEx <br />Shipped by: <br />Relinquished by: Date/Time: <br />Sample Return to Client ❑ 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 />-1 <br />OZ 10 61, afied <br />