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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 61723311 <br />DATE:4 /17/13 SSTF: S26911 & S26912 <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 />Report Required For: POTW/WWTP ❑ <br />ANALYSIS <br />REQUESTED <br />Notify ELI prior to <br />RUSK sample <br />Rece' t T,�ynp <br />— � <br />Other <br />e � <br />� <br />F <br />submittal for <br />C <br />Cool (s) <br />Special Report Formats – ELI must be notified <br />E .. <br />< <br />F additional charges <br />prior to sample submittal for the following:', <br />w <br />o <br />0 <br />and schedulin <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />'s <br />Ito <br />° <br />o <br />° <br />U <br />9 <br />` <br />o <br />Custody I <br />Y <br />Comments: <br />Other <br />EDD /EDT C1 Format <br />E 3 <br />a <br />U <br />c <br />V <br />F <br />P <br />E" <br />S&A Schedule Code : <br />N <br />Intact <br />Aj <br />Z <br />o <br />E <br />x <br />:5 <br />SW CODE 11 <br />Table 1 <br />Frequency 1, <br />Y <br />SignaturN <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />;mi <br />0 <br />Z <br />Match CAB ID <br />(Name, Location, <br />Date <br />Time <br />Y / N <br />Interval, etc ) <br />MATRIX <br />> <br />> <br />' SW -AWD <br />4/17/13 <br />10:45 <br />Water 1 <br />® <br />❑ <br />❑ <br />O <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />}. <br />2 SW -BPL <br />- <br />4/17/13 <br />11:00 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />C9 <br />❑ <br />Mull <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UJI <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />co <br />=31 <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />>- <br />S <br />❑ <br />❑ <br />❑ <br />❑ <br />I ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />I ❑ <br />0 <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />NO <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />1 ❑ <br />1010 <br />❑ <br />❑ <br />❑ <br />❑ <br />9 <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />10 <br />10 <br />10 <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />..� <br />,a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant DatelTime:4 /17/13 16:30 <br />Shipped by: FedEx <br />Received by: Daterrime: <br />Record <br />MUST be <br />Relinquished by: Date/ Time: <br />Shipped by: <br />Received by: te/Time:4 -, cl <br />CALP! <br />Signed <br />Sample Disposal: Return to Client El Lab Disposal ® <br />LABOR WRY USE ONLY <br />Sample Type # of fractions <br />e6 <br />