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Company Name: Cotter Corporation <br />Tracking No. 3692013 61523287 <br />Project Name: Schwartz - <br />DATE: 9/26/12 SSTF: _26569 <br />Report Mail Address: <br />Cotter Corporation - Cano City Mill <br />PO Box 1750; Canon City CO 8121 <br />Contact Name: Frank Adamic <br />rice: 1 -718- 275 -7413 ext 204 <br />Sampler Name i# other than Contact: <br />1- 303.542893 mines <br />Bob Tennant 1- 719 - 371 - 3009 -cetl <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215 -17 <br />voice Contact JoAnne Ary <br />�1: 1 -719- 275 -7x13 ext 209 <br />ix: 1- 719 - 215 -1669 <br />Purchase Order # <br />ELI Ouote #: <br />Report Required <br />Special Report <br />prior to sample <br />NELAC ❑ <br />Other <br />EDD/EDT ❑ <br />For: PO'M <br />Other <br />5 Number of Conlafnen <br />Sample Type: <br />-4 AWSVBO <br />X WI/Solids, Yevetatlon fposursay Ober <br />ANALYSIS REOUESTEO <br />Normal Turnaround (TAT) <br />L <br />F <br />. <br />RUSH Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />additional charges <br />and scheduling <br />Receipt Temp <br />6, ° C <br />sonadde «L« siousoa t 3101ii <br />Coo 1D( ) <br />Formats —ELI must b <br />submittal for the folIo� <br />A2LA ❑ Leve <br />Format <br />CustodysaI <br />Y (V <br />Intact <br />Y / N <br />Signature <br />Y / N <br />Match LAB [D <br />YIN <br />Comments: <br />Sgq Schedule Code : <br />GW CODE: <br />F uen <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc <br />Collection <br />Date <br />Collection <br />Time <br />MW - 6 <br />9,26112 <br />11:55 <br />W a t e r 6 <br />0 <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />O <br />O <br />❑ <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />D <br />0 <br />= <br />0 <br />I <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 />uU <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />= <br />v 4 t2oT1Gel <br />• <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />❑❑ <br />■ <br />•❑ <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 />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />• <br />8 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />._.,. <br />0 <br />0 <br />--Co <br />ion <br />❑ <br />• <br />■ <br />• <br />❑• <br />❑ <br />❑ <br />❑ <br />❑ <br />o,❑ <br />—' <br />is <br />0 <br />0 <br />• <br />0 0 <br />0 0 <br />• <br />0 0 <br />0 <br />0 <br />by: Date/Time: <br />by: Date/Time:tm0Io' <br />LA USE <br />Type ,_,. <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:9/27 /1216 30 <br />Shipped by: FedEx <br />Received <br />Received <br />Sam ple <br />ONLY <br /># of fractions <br />Relinquished by: Dat+e/Time: <br />Shipped by: <br />Retum to Client ❑ Lab Disposal ® <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 />