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Company Name: Cotter Corporation <br />Tracking No 3692013 62583594 <br />Project Name: Schwartz - - <br />DATE:2 /19/13 SSTF: S26794 & S26795 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 -17 <br />Contact Name: Frank Adamic <br />Voice: i 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 />Anne Ary <br />I3 ext 209 <br />Fax: 669 <br />Purchase Order #: <br />ELI Quote #: <br />Report Required For POTWIW <br />Other <br />Number of Containers <br />Sample B <br />X <br />2t2, air, Water aces/Solids, Yom, <br />ANALYSIS REQUESTED <br />(lvi) PunoJrwnj lrunoN <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />F additional charges <br />i. and scheduling <br />R T p <br />° C <br />L/ 3003 NUO YIA IOsfIP - n <br />U - total & dissolved - CODE #3 <br />Ra-226 total & dissolved CODE# 3 <br />C tD(s) <br />Special Report <br />prior to sample <br />NELAC • <br />Other <br />EDD/EDT • <br />Formats — ELI must be n� <br />submittal for the following: <br />A2LA 0 Level IV 0 <br />Format <br />Cusbd I <br />Y <br />Intact <br />Y thi <br />Signatu <br />Y <br />Match ID <br />Y� <br />RUSH Turnaround <br />Comments: <br />S&A Schedule Code : <br />SWCODEI1 <br />Table 1 <br />Frequency' 1, <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />I SW-AWD <br />2/19/13 <br />10:40 <br />Water 1 <br />® <br />❑ <br />• <br />❑ <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />- <br />2 SW-BPI. <br />2/19/13 <br />10:55 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />® <br />❑ <br />0 <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />tU <br />4 <br />❑ <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 />>"' <br />6 <br /># <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />G 150404 <br />a <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />m <br />8 <br />0 <br />0 <br />0 <br />0 <br />■ <br />■ <br />❑ <br />■ <br />❑ <br />❑ <br />■ <br />❑ <br />0 <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />■ <br />❑ <br />❑ <br />• <br />II <br />❑ <br />❑ <br />-I <br />10 <br />❑ <br />❑ <br />❑ <br />■ <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:2/19/13 16:30 <br />Shipped by: FedEx <br />Shipped by: <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Received by: `� > Daternme - -.R 0-1 '. <br />Sample Disposal: Return to Client ❑ Lab Disposal <br />�' ' • ORY 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 />