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v <br />CD <br />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No. 3692013 62583488 DATE: 1/22/13 SSTF: S26784 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Frank Adamic 1 -303 -642 -3893 mine phone <br />PO Box 1750; Canon City, CO 81215 -1750 Voice: 1 -719- 275 -7413 ext. 204 Bob Tennant 1 -719- 371 -3009 -cell <br />Invoice Address: Invoice Contact: JoAnne Ary Purchase Order #: ELI Quote #: <br />PO Box 1750 Tel: 1 -719- 275 -7413 ext 209 <br />Canon City, CO 81215 -1750 Fax: 1 -719- 275 -1669 <br />y= ° Notify ELI prior to <br />Report Required For: POTWMNVfP ❑ RUSH sample � a <br />Other a submittal for C <br />Special Report Formats — ELI must be notified F., o Q i= additional charges CQpILIr ID(s) <br />prior to sample submittal for the following: Fm' -� � and schedulin CC. <br />NELAC ❑ p A2LA ❑ Level IV ❑ o e o Comments: Custody <br />Other 8 W <br />CL a co Y <br />EDD /EDT ❑ Format ; ffi E S&A Schedule Code : IntacY / N <br />Z r GW CODE: <br />SAMPLE g N 0 U) Signature <br />IDENTIFICATION Collection Collection" w Z Y / N <br />F <br />(Name, Location, Date Time r u Match LAB ID <br />Interval, etc) MATRIX <br />w Y/N <br />Domestic Well 1/22/13 12:00 Water 6 ® ❑ ❑ ❑ ❑ ❑ O ❑ ❑ ❑ ® ❑ <br />2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />4 D ❑ ❑ ❑ ❑ ❑ ❑ 11 11,11 ❑ ❑ C. Iml <br />s ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑„ <br />6 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <Z', <br />8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />9 ❑ ❑ ❑ ❑ ❑ !01 ❑ ❑ ❑ ❑ ❑ ❑ <br />10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />Custody Relinquished by: Bob Tennant Datelrime:1 /22/13 16:30 Shipped by: FedEx Received by: Daterr-ime: <br />CD <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 />L/15- <br />Record <br />Relinquished by: Date/Time'. <br />Shipped by: <br />Received by: Daterrime: —d,3 -�3 <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal 0 <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />L/15- <br />