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Company Name: Cotter Corporation <br />Tracking No. 3692013 61650990 <br />Project Name: Schwartz - <br />DATE 9120112 SSTF: $26607 & S266O8 <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 />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 />; .ti 6 <br />Report Required For. POTWNVVYTP 0 <br />Other <br />Number of Containers <br />AWSVSO <br />tic I � Yeoea�on. <br />ANALYSIS REQUESTED <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 e <br />**low a « ' d ' L 378111 <br />• <br />Cooler I ) <br />Custody <br />Y <br />Intact <br />Y / N <br />Signature <br />YIN <br />Match LAB ID <br />Y / N <br />Special Report <br />prior to sample <br />NELAC ❑ <br />Other <br />EDD/EDT ■ <br />Formats — ELI must be notified <br />submittal for the following: <br />A2LA ❑ Level N <br />Format <br />II <br />Purl HSfki <br />Comments: <br />S&A Schedule Code : ' <br />GW CODE: <br />11111 <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />I Sump -1 <br />9/20/12 <br />12:00 <br />Water 8 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />> <br />2 Sump-8 <br />9/20/12 <br />13:30 <br />Water 6 <br />® <br />❑ <br />❑ <br />0 <br />❑ <br />• <br />• <br />❑ <br />❑ <br />• <br />® <br />❑ <br />�Q <br />3 <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />• <br />• <br />• <br />❑ <br />❑ <br />• <br />❑ <br />J <br />ILI <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />5 <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />MCGl 7 *MI <br />6 <br />0 <br />• <br />0 <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />• <br />0 <br />d <br />0 <br />0 <br />0 <br />0 - <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />ce <br />a <br />000 <br />IN <br />;CO <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />-..11 <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 Tennant Date/Time:9/20/12 16:30 <br />Shipped <br />by: FedEx <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: 7l Date/Time: ?Ai / 8 <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 />Lz 61. abed <br />