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v <br />CD <br />CD <br />N <br />Cn <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 <br />Company Name: Cotter Corporation <br />Project Name: Schwartz - <br />Tracking No 3692013 61723434 <br />DATER /30/13 SSTF: , S26872 ' <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 it <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: POTWiWWTP El <br />ANALYSIS <br />REEOVESTEu <br />Notify EL! prior to <br />RUSH RUSH sample <br />R P <br />° <br />Other <br />< <br />submittal for <br />C <br />Gaoler !D(s <br />Special Report Formats – ELI must be notified <br />.. <br />'B'D <br />� <br />$ <br />� <br />rr additional charges <br />prior to sample submittal for the following: <br />m'-' <br />o <br />� and schedulin <br />Custody deal <br />N�rC ❑ A21.A ❑ Level IV ❑ <br />is <br />Comments: <br />EDD /EDT Format <br />❑ <br />< � <br />r <br />t <br />S&A Schedule Code : <br />Intact <br />Y <br />SW CODE 11 <br />V <br />l <br />1 <br />x Table 1 <br />FregoencA 1, <br />Signatuvr" <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Z <br />it <br />Match LAMB ID <br />(Name, Location, <br />Date <br />Time <br />Y / N <br />Interval etc ) <br />MATRIX <br />~ <br />SW ARH <br />5013 <br />1310 <br />Water 7 <br />❑ <br />❑ <br />O <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 />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />au <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1110 <br />❑ <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0101 <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />—0–"o <br />CDP <br />F.. <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />8 <br />010,0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />01010 <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 Date/Time:5/8/13 16:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Record <br />Relinquished by: DatelTime: <br />Shipped by: <br />Received by* ' Daterrime: - <br />MUST be <br />Signed <br />Sample Disposal: Retum to Client ❑ Lab Disposal ® <br />LABOJ�JkTORY USE ON Y <br />Sample T # of fractions <br />