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v <br />N <br />V <br />ARM Chain of Custody and Analytical Request Record <br />PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page i of 1 <br />Company Name: Cotter Corporation <br />Project Name: Schwarz - <br />Tracking No 3692013 61723410 <br />DATER /30/13 SSTF: , S268681 S26869 <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. POTWNWVTP Cl <br />ANALYSIS <br />REQUESTED <br />Notify ELI prior to <br />RUSH sample <br />Recei t T p <br />f <br />Other <br />Special Report Formats - ELI must be notified <br />.. <br />.- <br />a <br />submittal for <br />additional charges <br />C <br />Co ID( s)o <br />Co <br />prior to sample submittal for the foffowing: <br />AW <br />o <br />t and schedulin <br />Custody Seal <br />� <br />Comments: <br />NELAC ❑ A2LA ❑ Level IV El <br />� w � <br />� <br />� <br />Q <br />Y/N <br />Other <br />EDD/EDT [] Format <br />< <br />a <br />S&A Schedule Code: <br />Intact <br />Z <br />c <br />a <br />a, <br />�_ <br />~ <br />SW CODE 11 <br />Table 1 <br />Frequency 1, <br />Y/ N <br />Signature <br />Y/ N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Match LAB l0 <br />(Name, Location, <br />Date <br />Time <br />° <br />4 <br /># <br />YIN <br />Interval, etc <br />MATRIX <br />:1 <br />� <br />� <br />'- <br />I <br />I <br />I <br />I <br />C 0 t i <br />1 SW -AWD <br />5/4113 <br />Water 7 <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />1 D c)-s- <br />>- <br />2 SW -BPL <br />5-4-13 <br />Water 7 <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />% <br />Z <br />3 <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />GO <br />W <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />5 <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 />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />ea <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />001-0 <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Dater ime:5/4 /1316:30 <br />Shipped by: FedEx <br />Received by: DatefTime: <br />Record <br />MUST be <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: Date✓rime: - <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LA$O RY USE ONLY <br />Sample Type # of fractions <br />