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company Name: Cotter Corporation <br />Tracking No. 3692013 61650969 <br />Project Name: Schwartz - <br />DATE: 9/13/12 SSTF: S26638 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 8121 <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 />Invoice Contact: JoAnne Ary <br />el: 1- 719 - 275 -7413 ext. 209 <br />ax: 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 a <br />For: POTV1 <br />Other <br />, api5 Raereos X <br />'uogere6oA 'SPfISnivo$ 'D AC ' � <br />09ASMV �- <br />:add, aldwsS Z q <br />SAUFRIII JO lagwfN <br />ANALYSES RE QUESTED <br />Normal Turnaround (TAT) <br />- <br />. <br />RUSH Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />additional charges <br />and scheduling <br />Receipt Temp <br />t-kC <br />HZ. 0 1 0 •40 0 d • Z WW1 <br />• <br />1 <br />•' - r I' s) <br />.1 a <br />Custody eal <br />Y <br />Intact <br />Signatu <br />Y / <br />Match B ID <br />Yl tb <br />- ELI must b <br />submittal for the follow <br />A2LA 0 Level <br />Format <br />Comme: <br />S&AC dule Code : <br />F r uen <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />0 <br />0 <br />Collection <br />Time <br />1 <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 />>- <br />2 Sump -10 <br />9113/12 <br />_ <br />13:30 <br />Water 6 <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />0 <br />. <br />0 <br />❑ <br />= <br />0 <br />• <br />• <br />3 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />IW <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ <br />= <br />. <br />• <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />OtACI <br />ce <br />111 <br />a <br />5 <br />0 <br />0 <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />co <br />a <br />7 <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />C 3 <br />Er <br />1 1 <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />a3 <br />• <br />9 <br />D <br />• <br />• <br />. <br />0 0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />-.a: <br />10 <br />0 <br />0 <br />0 0 <br />0 <br />• <br />0 <br />• <br />•'❑ <br />_ <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Daterrime:9 /13 /12 16:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Sh pped by: <br />Received b Date/Time: cip117/ I <br />Sample Disposal: Return to Client Q Lab Disposal 10 _ _ <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 />