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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 />Company Name: Cotter Corporation <br />Project Name: Schwartz - <br />Tracking No 3692013 61723212 <br />DATE:3 /19/13 SSTF: S26878 & S26879 <br />Report Mail Address: <br />Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill <br />Contact Name: Frank Adamic <br />1 -303 -642 -3893 mine phone <br />PO Box 1750; Canon City, CO 81215 -1750 <br />Voice: 1- 719 - 275 -7413 ext. 204 <br />Bob Tennant 1 -719- 371- 3009 -cell <br />Invoice Address: <br />Invoice Contact JoAnne Ary <br />Purchase Order* <br />ELI Quote #: <br />PO Box 1750 <br />Tel: 1- 719- 275 -7413 ext. 209 <br />Canon City, CO 81215 -1750 <br />Fax: 1 -719- 275 -1669 <br />Notify ELI prior to <br />Receipt hemp <br />Report Required For: POTWNWVTP El <br />RUSH sample <br />C <br />Other <br />Special Report Formats — ELI must be notified <br />a <br />4 o � <br />a <br />.- <br />Q <br />Q <br />o <br />a <br />a <br />submittal for <br />F additional charges <br />e filer ID(s) <br />prior to sample submittal for the following: <br />E. ; � <br />- <br />u <br />o <br />0 <br />t and scheduling <br />Custody Seal <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />o <br />0 <br />Comments: <br />Y 1 <br />Other <br />E D /EDT ❑ Format <br />o y <br />`� < vx <br />2' <br />`o <br />v <br />0 <br />~ <br />E S&A Schedule Code, <br />Intact <br />�I <br />i 01 <br />' SW CODE 11 <br />Y CN <br />'s <br />20 <br />-6 <br />0 <br />i <br />x Table 1 <br />f= requency� 1, <br />Signature <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />°a <br />a <br />o <br />Match LAB ID <br />{Name, Location, <br />Date <br />Time <br />�, <br />J2 <br />Y / N <br />Interval etc ) <br />MATRIX <br />> <br />> <br />SW -AWD <br />3/19/13 <br />10:20 <br />Water 1 <br />® <br />D <br />❑ <br />[1 <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />2 SW -SPL <br />3/19/13 <br />10:40 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />3 <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />t <br />4 <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />5 <br />1-] <br />1 D 1 <br />❑ <br />❑ <br />[1 <br />❑ <br />11 <br />1 ❑ <br />D <br />D <br />1E-3 <br />❑ <br />6 <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />t, <br />,- <br />7 <br />O <br />1:1 <br />❑ <br />❑ <br />D <br />11 <br />❑ <br />D <br />11 <br />❑ <br />1 ❑ <br />8 <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />D <br />❑ <br />❑:� <br />s <br />1 <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />D <br />D <br />El <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Date/Time:3 /20/13 16:30 <br />Shipped by: FedEx <br />Received by: Date/rime: <br />Record <br />Relinquished by: Daterrime: <br />Shi peed by: <br />Received by: te�me: ._� <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORAJPRY USE ONLY <br />Sample T # of fractions <br />co <br />0 <br />CD <br />M <br />ca <br />a <br />