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Company Name: Cotter Corporation <br />Tracking No. 3692013 61650945 <br />Project Name: Schwartz - <br />DATE: 9/0/612 SSTF: S26 <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 />`' 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 <br />Special Report <br />prior to sample <br />NELAC ❑ <br />Other <br />EDD/EDT ❑ <br />For: POTW/V <br />Other <br />notffied <br />I <br />f Number of CoMeinefs <br />Sample Type: <br />— AWSVBO <br />Q ws, yeyefatlon, <br />X gloomy Other <br />u EV,A E 1 SE S REO:l S * En <br />, <br />Normal Turnaround (TAT) <br />p <br />t <br />RUSH Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />additional charges <br />and scheduling <br />Rece t Temp <br />iQ <br />°C <br />sslid .z. a -z 3'18V1 <br />1 " <br />C er ID s) <br />Formats — ELI must be <br />submittal for the follows <br />A2lA ❑ Level <br />Format <br />C I <br />Custody <br />Y <br />intact <br />Y /ai <br />Signature <br />Y /� <br />Match Likp ID <br />Y/ Vi <br />Comments: <br />SBA Schedule Code : <br />GW CODE: <br />F <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />' <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />T <br />❑ <br />❑ <br />❑ <br />■ <br />. <br />■ <br />s Mine Refill water <br />9/06/12 <br />15:00 <br />Water 5 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />IR <br />❑ <br />m <br />• <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />US <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑0 <br />0 <br />=' <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />G Ial:pCw7q <br />• <br />• <br />• <br />• <br />• <br />8 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ <br />❑ <br />� <br />• <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />�--- <br />0 <br />0 <br />,,E <br />s <br />• <br />e <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />O <br />co <br />• <br />• <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />• <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:9 /07 /1216:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Shipped by <br />Received by: v i t , Date/Time: COAL 1Vci <br />Sarni* Disposal: Return to Client 0 Lab Disposal <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />CI <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 />