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CD <br />0 <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 />Company Name: Cotter Corporation <br />Project Name: Schwartz - <br />Tracking No 3692013 61723281 <br />DATER /10/13 SSTF: 526882 & S26884 <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 />REQUESTED <br />Notify ELI prior to <br />Receipt Temp <br />Report Required For POTWIWWTP ❑ <br />RUSH sample <br />�r C <br />Other <br />a <br />submittal for <br />C er ID(s) <br />Special Report Formats — ELI must be notified <br />F additional charges <br />prior to sample submittal for the following: <br />b'> m p <br />w <br />a <br />v <br />and schedulin <br />Custod eal <br />;? <br />Comments: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />Other <br />$ <br />$ <br />3 <br />a <br />E <br />W <br />Intact <br />EDD /EDT [I Format <br />�a <br />r <br />a' <br />V <br />F <br />SA Schedule Code <br />a1°� <br />$ <br />z <br />' <br />i <br />SW CODE I I <br />Table 1 <br />Frequency 1, <br />Y / N <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Ir <br />Match LAB ID <br />(Name Location, <br />Date <br />Time <br />° <br />Y / N <br />Interval etc ) <br />MATRIX <br />:1 <br />' <br />SW AWD <br />4/10113 <br />8:45 <br />Water 1 <br />® <br />1 ❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />0,010 <br />❑ <br />y.. <br />2 SW-BPL <br />4/10/13 <br />8:55 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />Z <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UJ <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />=I <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />}" <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑.,,. <br />7 <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />pG <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 m <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />...� <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Datemme:4 /10/13 16:30 <br />Shipped by: FedEx <br />Received by: Datelrme: <br />Record <br />Relinquished by. DatelTime: <br />Shipped by: <br />Received by: ` Date/Time: Y—/;)—) <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />