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Chain of Custody and Analytical Request Record <br />41110=0 0-p-M PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of 1 <br />Company Name: COttef Corporation <br />Tracking No. 3692013 61723298 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 -1750 <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215 -1750 <br />I Report Required For POTW/WWTP ❑ <br />Other <br />Special ReFw afw - EU u t be tilled <br />prior to sample <br />NELAC ❑ <br />Other <br />EDD/EDT [] F <br />IDENTIFIC <br />(Name, L <br />K <br />2 SW ARH <br />4 <br />4 <br />6 <br />�r <br />�e <br />10 <br />v <br />CD <br />0 <br />Custody <br />Record <br />MUST be <br />Signed <br />Project Name: Schwartz - <br />DATE: 4/10/13 SSTF: A=@W& S26886 & S26887 <br />Contact Name: Frank Adamic <br />Voice: 1- 719 -275 -7413 ext 204 <br />Invoice Contact JoAnne Ary <br />Tel: 1 -719- 275 -7413 ext. 209 <br />Fax: 1 -719- 275 -1669 <br />ANALYSIS REQUESTED <br />submittal for the following: > <br />> o <br />o <br />A2LA F-1 Level IV ❑ 0 <br />0 <br />ormat"` r <br />r <br />y ° <br />° <br />e <br />E e <br />V <br />SOMME <br />31313 <br />3o000 <br />so BE <br />BOMBS <br />SOMME <br />D0000 <br />D000n <br />BOMBS <br />1-0000 <br />Shipped . <br />Q <br />2 <br />E <br />E <br />Z <br />UQOC <br />Doo <br />DOME <br />Doo E <br />Doo 0 <br />D000 <br />D000 <br />DD OE <br />Doo 0 <br />Uoo© <br />Sampler Name if other than Contact <br />1- 303 -642 -3893 mine phone <br />Bob Tennant 1 -719 -371- 3009 -cell <br />Purchase Order #: I ELI Quote It <br />�-Q -- I <br />Notify ELI prior to <br />RUSH sample Receipt T mp <br />submittal for C <br />additional charges Cooler lUs) <br />t and schedulin <br />Comments: Custody l <br />Y l( <br />S&A Schedule Code: Intact <br />F SW CODE 13 Y/ N <br />z Table 1 Signature <br />3 Frequency 4, Y / N <br />Match LAB ID <br />Y/N <br />D� <br />90 m <br />D� <br />Dew■ <br />D� <br />D■� <br />D� <br />LABORA <br />Date/Time: <br />Date/Time: q -j <br />RY USE ONLY <br /># of frac <br />Q <br />2 <br />E <br />E <br />Z <br />UQOC <br />Doo <br />DOME <br />Doo E <br />Doo 0 <br />D000 <br />D000 <br />DD OE <br />Doo 0 <br />Uoo© <br />Sampler Name if other than Contact <br />1- 303 -642 -3893 mine phone <br />Bob Tennant 1 -719 -371- 3009 -cell <br />Purchase Order #: I ELI Quote It <br />�-Q -- I <br />Notify ELI prior to <br />RUSH sample Receipt T mp <br />submittal for C <br />additional charges Cooler lUs) <br />t and schedulin <br />Comments: Custody l <br />Y l( <br />S&A Schedule Code: Intact <br />F SW CODE 13 Y/ N <br />z Table 1 Signature <br />3 Frequency 4, Y / N <br />Match LAB ID <br />Y/N <br />D� <br />90 m <br />D� <br />Dew■ <br />D� <br />D■� <br />D� <br />LABORA <br />Date/Time: <br />Date/Time: q -j <br />RY USE ONLY <br /># of frac <br />D� <br />90 m <br />D� <br />Dew■ <br />D� <br />D■� <br />D� <br />LABORA <br />Date/Time: <br />Date/Time: q -j <br />RY USE ONLY <br /># of frac <br />