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v <br />00 <br />0 <br />0 <br />jJIM 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 61723427 <br />DATER /30/13 SSTF: , S26871, 526873 <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. POTWAArWTP ❑ <br />AN <br />LfS$.' <br />REODUw•: <br />Erg <br />Notify ELI prior to <br />RUSH sample <br />Recejpt emp <br />Other <br />Special Report Formats — ELI must be notified <br />a <br />submittal for <br />additional charges <br />C <br />C r ID(s) <br />.. o <br />w <br />o <br />o <br />a <br />prior to sample submittal for the following: <br />IA,>! <br />> 1 <br />o <br />$ <br />and scheduling <br />Custody Seal <br />Comments: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />Other <br />� <br />2 <br />2 <br />E <br />Y <br />EDD /EDT ❑Format <br />`% ` <br />Ep <br />S&A Sd*dule Code : <br />Intact <br />SW CODE I 1 <br />Y <br />° <br />°° <br />_ <br />Z <br />M <br />Table 1 <br />Frequency) 1, <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />ac <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />�, <br />„ <br />Y / N <br />Interval etc <br />MATRIX <br />> <br />> <br />~ <br />' SW -FBRG <br />518/13 <br />830 <br />Water 3 <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />;s.r <br />2 SW -LLHG <br />5 -8 -13 <br />1020 <br />Water 3 <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />CI <br />❑ <br />® <br />❑ <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />tJ <br />4 <br />❑ <br />1 ❑ <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 />g <br />❑ <br />❑ <br />❑ <br />❑ <br />lo <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑.. <br />7 <br />010,0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />WX- <br />cc <br />8 <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Icr- <br />cc <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />,. <br />to <br />0101 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob TennInt DatefTime:501316:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Record <br />Relinquished by: Dateffime: <br />Shipped by: <br />Received by: Dateliime: 4 ` et <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABOFWrORY USE UNLT <br />Sample T # of fractions <br />