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fn <br />CD <br />N <br />A <br />0 <br />N <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 61723250 <br />DATER /03113 SSTF: S2686O <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/WVVTP El <br />ANALYSIS <br />REQUESTED <br />Notify ELI prior to <br />RUSH sample <br />Receipt Temp <br />Other <br />submittal for <br />-' oL C <br />Special Report Formats - ELI must be notified <br />= .. E' <br />a <br />F additional charges <br />Cooler ID(s) <br />nts <br />prior to sample submittal for the following: <br />&> > <br />c <br />o <br />0 <br />_ <br />and schedulin <br />4 SL <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />�, � <br />C <br />U <br />_ <br />Comments: <br />y <br />Other <br />E3 <br />`N a <br />2 <br />E <br />' <br />tntac� / N <br />EDD /EDT ❑Format <br />a <br />S&A Schedule Code <br />Z T <br />a� <br />° <br />q <br />'0 <br />a° <br />z <br />I'_ SW CODE I I <br />x Table i <br />:3 Frequency 1, <br />Y/ N <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />v <br />n <br />.2 <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />a <br />Interval, etc <br />MATRIX <br />:3 <br />� <br />Y / N <br />I SW AWD <br />4/03113 <br />11:00 <br />Water 7 <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />�-- <br />2 <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 />l4i <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />C <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />C. <br />7 <br />❑ <br />❑ <br />❑ <br />O 10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />OC <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />co <br />s <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 />of <br />' <br />Custody <br />Relinquished by: Bob Tennant Date/Time:4 103/13 16:30 <br />Shipped by: FedEx <br />Received by: Date rime: <br />Record <br />MUST be <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: DateTme: <br />Signed <br />9 <br />Sample D' <br />mp Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />V <br />13 .0 <br />