2013-05-08_HYDROLOGY - M1977300 - Laserfiche WebLink

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d CD CD N co 0 N A 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 Project Name: Schwartz - Tracking No. 3692013 62583496 DATE: 1/24/13 SSTF: 526788 Report Mail Address: Sampler Name if other than Contact: Cotter Corporation - Canon City Mill Contact Name: Frank Adamic 1- 303 -642 -3893 mine phone PO Box 1750; Canon City, CO 81215 -1750 Voice: 1-719-275-7413 ext. 204 Bob Tennant 1 -719- 371 - 3009 -coif Invoice Address: Invoice Contact JoAnne Ary Purchase Order # ELI Quote #. PO Box 1750 Tel: 1- 719- 275 -7413 ext. 209 Canon City, CO 81215 -1750 Fax: 1- 719 - 275 -1669 Report Required For. POTWMNYrP ❑ ANALYSIS REQUESTED Notify ELI prior to RUSH sample Receip�t Temp Other Special Report Formats - ELI must be notified to for the following: >° a fim submittal for additional charges t and scheduling -. C Cool r ID(s) prior sample submittal Custody Seal NELAC ❑ A2LA ❑ Level IV ❑ Other g o y y 3 E Comments: Y / V� EDD /EDT El Format �, as m e E S8A Schedule Code: Intact , Y Z W € r GW CODE: N � C:J Signatu SAMPLE IDENTIFICATION Collection Collection J Fre uen Match LAB ID (Name, Location, Date Time Y / N Interval, etc) MATRIX " Mine Refill 1124113 12:20 Water 5 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ �- 2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ' a ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Lai ° ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ s ❑ ❑ ❑ a ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ G ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ F. ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ e a ❑ ❑ ❑ ❑ ❑ a ❑ ❑ ❑ ❑ ❑ 9 ❑ ❑ 10 ❑ a ❑ ❑ a ❑ ❑ ❑ ❑ -1 10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O Custody Relln wished by: Bob Tennant Daterrime:1/24/13 16:30 Shi by: FedEx Received by: Date/Time: Record Relinquished by: DateJTime: Shipped by: Received b Date/Time:f- Z -1 J MUST be Signed Sample Disposal: Return to Client ❑ Lab Disposal ® LAB TORY USE ONLY Sample T # of fractions OF