2013-04-11_HYDROLOGY - M1977300 (2)

Home Browse Search

Chain of Custody and Analytical Request Record PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of 1 Company Name: Cotter Corporation Tracking No 3692013 62583648 Report Mail Address: Cotter Corporation - Canon City Mill PO Box 1750; Canon City, CO 81215 -1750 Invoice Address: PO Box 1750 Canon City, CO 81215 -1750 Report Required For. POTWNVWTP ❑ Other Special Report Formats — ELI must be notified prior to sample submittal for the following: NELAC ❑ A2LA ❑ Level IV ❑ Other EDD /EDT ❑ Format SAMPLE IDENTIFICATION (Name, Location, Interval, etc) ' SW -AWD 12:15 2 SW-BPL 3 4 5 6 7 9 10 Custody Record MUST be Signed Collection Date 2128/13 2/28/13 Collection Time 11:50 Relinquished by: Bob Tennant Date/Time:3 /01/13 16:30 Relinquished by: Date/Time: Sample Disposal: Project Name: Schwartz - DATE:2 /28/13 SSTF: S26813 & S26814 Contact Name: Frank Adamic Voice: 1- 719 -275 -7413 ext. 204 Sampler Name if other than Contact: 1- 303 -642 -3893 mine phone Bob Tennant 1- 719 - 371 -3009 -cell Invoice Contact: JoAnne Ary Tel: 1- 719- 275 -7413 ext. 209 Fax: 1 719 - 275 - 1669 Purchase Order #: MATRIX Water 1 0 ❑ Water 1 Return to Client ❑ Rk01) w g 0 2 ❑ ❑ 0 0 ❑ ❑ 0 ❑ 0 0 ❑ ❑ ❑ 3 r 0 0 0 0 ❑ ❑ ❑ 0 0 0 0 ❑ ❑ ® ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 0 ❑ 0 0 ❑ 0 0 0 Lab Disposal ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ 0 ❑ ❑ ❑ 0 0 0 ELI Notify ELI prior to RUSH sample submittal for additional charges and scheduling Comments: S&A Schedule Code : SW CODE 111 Table 1 Frequency' 1, ❑ ❑ ❑ C.13m DDSs 0 0 0 0 0 0 0 0 0 0 0 0 0 Shipped by: FedEx Received by: Date/Time: Quote #: Receipt Temp S.4 °C Cooler ID(s) CustodVal Intact Y 45) Signature Match i t ID Y/N IOC Shipped by: Received by :I, Date/Time: 31,E li3 f' LABORATORY USE ONLY Sample Type # of fractions