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Company Name: Cotter Corporation <br />Tradcing No. 3692013 62583587 <br />Project Name: Schwartz - - <br />DATE: 2/19/13 SSTF: S26797 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215- <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 An+ <br />413 ext. 209 <br />Fax: 1669 <br />Purchase Order It <br />ELI Quote <br />Report Required For PO1W/ <br />Other <br />f Number of Conbines <br />Sample Type: <br />AWSVBO <br />N�r a xeoetebon <br />X fl► <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 />t emp • <br />eG o C <br />U - dissolved only - CODE e1 l <br />Re-226 total & dissolved COOEI 3 <br />SEE ATTACHED TABLE 1 1 <br />Coat <br />Custody = I <br />Y <br />Intact <br />Y <br />Sign: l <br />Y <br />Match LAB ID <br />Y 1 N <br />Special Report Formats - ELI must be notified <br />prior to sample submittal for the follow <br />NELAC ❑ A2LA ❑ Level IV <br />Other <br />EDD/EDT Format <br />RUSH Turnaround <br />Comments: <br />SBA Schedule Code : <br />SW CODE II 3 <br />Table 1 <br />Frequency' 4, <br />Two coolers <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />' <br />0 <br />0 <br />0 <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />�- <br />2 SW ARH <br />2/19/13 <br />12:40 <br />Water 7 <br />❑ <br />❑ <br />• <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® . <br />❑ <br />Table 1 <br />O <br />3 <br />❑ <br />D <br />❑ <br />D <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />w <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />CI <br />• ■ <br />D <br />S <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />6 <br />❑ <br />■ <br />a <br />❑ <br />■ <br />❑ <br />❑ <br />0 <br />❑ <br />❑.❑ <br />❑ <br />' <br />❑ <br />❑ <br />D <br />❑ <br />III <br />❑ <br />❑ <br />D <br />© <br />© <br />■ <br />Ct <br />e <br />D■❑❑❑ <br />0 <br />D❑❑ <br />D <br />❑`❑ <br />m <br />a <br />❑ <br />■ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />© <br />0 <br />❑ <br />❑ <br />10 <br />❑ <br />• <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />IS <br />❑ <br />❑ <br />❑ <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennagt Date/Time:2/19/1316 30 <br />Shipped by: FedEx <br />Shipped by: <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />. •� `x <br />Received by €?aterfime . g- <br />Sample Disposal: Return to Client D Lab Disposal <br />LAB TORY 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 />9Z 1 VZ abed <br />