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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 61723403 <br />DATER /30/13 SSTF: 526896, S26 897,S26898,S26899,S26900,S26864 <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 />ANALYSIS <br />REQUr~STED <br />Notify ELI prior to <br />R�pF �-em <br />Report Required For. POTWNWVTP ❑ <br />RUSH sample <br />D a C <br />Other <br />Special Report Formats — ELI must be notified <br />.. <br />n <br />a <br />submittal for <br />F additional charges <br />Cooler !D(s) r <br />lod <br />prior to sample submittal for the following: <br />t- � <br />c <br />g <br />0 <br />� <br />t and schedulin <br />Cush eai <br />C <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />s E 3 <br />Comments: <br />0 <br />Y <br />Other <br />EDD /EDT ❑ Format <br />< �r <br />G `� <br />c <br />$_ <br />E <br />W <br />SBA Schedule Code : <br />Intact <br />e <br />o <br />€ <br />z <br />SW CODE 1 1 <br />Table 1 <br />Frequency 1, <br />Signature - <br />Y <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />b <br />N <br />o <br />z <br />a <br />MatcY LAB ID <br />(Name, Location, <br />Date <br />Time <br />m <br />a <br />(pV <br />Interval, etc <br />MATRIX <br />:1 <br />elm: <br />�" <br />' SW-A001 <br />4130/13 <br />9:43 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />2 SW -SDIS <br />4/30113 <br />10:23 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />3 SW-PL <br />4/30/13 <br />14:27 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />rJ <br />4 SW -OS <br />4/30/13 <br />15:07 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />r <br />5 SW-BOS <br />4/30/13 <br />15:48 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />6 SW-GS <br />4130/13 <br />15:58 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />® <br />❑ <br />�... <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />IdC <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑❑ <br />❑ <br />❑ <br />Ice <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />010.0 <br />Custody <br />Relinquished by: Bob Tennant Date/Time:4 /30/13 18:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Record <br />MUST be <br />Relinquished by: Date/rime: <br />Shipped by: <br />Received by: te/Time: _ <br />Signed <br />Sample Disposal: Return to Client 13 Lab Disposal ® <br />LApe ORY USE ONLY <br />Sam le T # of tractions <br />