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Company Name: Cotter Corporation <br />Tracking No. 3892013 61651003 <br />Project Name: Schwartz - <br />DATE: 9127112 SSTF: S26570 <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 />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 />; 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 />N ❑ <br />For: POTWA <br />Other <br />notified <br />I <br />f Number of Containers <br />Type: Sample <br />H-I AWSV Q <br />Air, Water x asay Qatar '� Y tin, <br />ANALYSIS REQUESTED <br />Normal Turnaround (TAT) <br />P <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 />its ° C <br />wII «S. ■ou»d - z 31M <br />+ <br />Cooler !D(s) <br />4 '' c "' - <br />Formats — ELI must be <br />submittal for the following: <br />A2LA ❑ Level <br />Format <br />Custody© I <br />Intact <br />Y 1 N <br />Signature <br />Y / N <br />Match LAB ID <br />Y / N <br />Comments: <br />S&A Schedule Code : <br />GW CODE: <br />F uen <br />EDD/EDT • <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />i MIN - 7 <br />9/27/12 <br />13:55 <br />W a t e r 6 <br />® <br />D <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />El <br />D <br />• <br />2 <br />o <br />0❑ <br />o <br />0 <br />■❑❑❑❑ <br />a❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />0 <br />ill <br />U, <br />• <br />• <br />4 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />_► <br />I <br />5 <br />D <br />❑ <br />❑ <br />❑ <br />❑❑ <br />o❑ <br />o <br />o <br />6 <br />❑ <br />❑ <br />0 <br />❑ <br />D <br />❑ <br />I7 <br />❑ <br />0 <br />❑ <br />❑ <br />Q Gr alc .o r 31 <br />OE <br />CO <br />■ <br />0 <br />❑ <br />0 <br />❑ <br />❑ <br />D <br />0 <br />❑ <br />❑ <br />0 ❑ <br />• <br />e <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />_m <br />1 <br />1 <br />• <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />0 <br />1 <br />• <br />• <br />• <br />10 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />0 <br />Custody <br />Record <br />MUST be <br />Signed <br />R , .. . - .. :: • b T - n : nt Date/Time:9/28/1216 30 <br />Relinquished by: DateRane: <br />Sh' !,. - . b : FedEx <br />Sh'pped by: <br />Received b : Date/Time: <br />Received by: irlp Date/Time <br />Sample : Return to Client • Lab Disposal ® <br />LABORATORY USE ONLY <br />Samjle 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 />