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Company Name: Cotter Corporation <br />Tracking No 3692013 62583570 <br />Project Name: Schwartz - <br />DATE:2 /12/13 SSTF: S26792 & S26793 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, Co 81215 -1750 <br />Contact Name: Frank Adamic <br />-- 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 />i» 209 <br />Fax: 1 <br />Purchase Order #: <br />ELI Quote #: <br />Report Required For: POTWNVWTP <br />Other <br />Numbsr of Containers <br />Sample Type: <br />AWSVBO <br />&r, Oiler $ow&Solids, yepetatbn, <br />X gleamy Qsher <br />_ <br />ALYS S 11U :. : „ .:" n <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />P additional charges <br />t and scheduling <br />R Temp <br />'� ° C <br />U - dissolved only - CODE #1 <br />U - total & dissolved - CODE 03 <br />Ra -226 total & dissolved CODE*3 <br />L algal <br />I s) <br />Special Report Formats — ELI must be notified <br />prior to sample submittal for the following: <br />NELAC 0 A2LA ❑ Level IV 0 <br />Other <br />EDD/EDT 0 Format <br />Custody Seal <br />Y <br />Intact <br />Y <br />Signature <br />Y / N <br />Match LAB ID <br />Y/ <br />' <br />RUSH Turnaround <br />Comments: <br />S&A Schedule Code : <br />SW CODE Ii <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 />1 SW - AWD <br />2/12/13 <br />9:30 <br />Water 1 <br />■ <br />El <br />❑ <br />❑ <br />❑ <br />• <br />• <br />C) <br />❑ <br />❑ <br />® <br />• <br />› - <br />2 SW-BPL <br />2/12/13 <br />10:00 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />0 <br />® <br />• <br />= <br />3 <br />0 <br />• <br />0 <br />0 <br />❑ <br />D <br />D <br />D <br />D■ <br />D <br />tLI <br />4 <br />❑ <br />❑ <br />• <br />❑ <br />0 <br />❑ <br />❑ <br />D <br />• <br />D <br />❑ <br />D❑ <br />C mcntxLL15 <br />5 <br />D 0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />D <br />0 <br />0 <br />D <br />0 <br />D <br />0 <br />0 <br />0 DD <br />fS <br />6 <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />D <br />II— <br />7 <br />0 <br />0 <br />a <br />•❑ <br />D <br />D■ <br />O <br />ireC <br />ete <br />8 <br />0 <br />0 <br />0 <br />0 <br />. <br />• <br />0 <br />0 <br />0 <br />0 <br />rxi <br />9 <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />• <br />D❑ <br />❑ <br />D <br />- <br />10 <br />s <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />D <br />D <br />❑ <br />j <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Tme:2/13/13 16:30 <br />Shipped by: FedEx <br />Received byi Date/Time: a'j <br />Relinquished by: Date/Time: <br />Shipped by: <br />014"i <br />Received by Date/Time: <br />Sample Disposal: Return to Client • Lab Disposal ® <br />LABORATORY 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 />