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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: Schwarz - - <br />Tracking No 3692013 61723342 <br />DATE:5 /16113 SSTF: S26976 toS26978 &S26980 TO S26983 <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 exk 209 <br />Canon City, CO 81215 -1750 <br />Fax: 1 -719- 275 -1669 <br />At "A <br />_Y:As <br />Notify ELI prior to <br />Receipt Temp <br />Report Required For POTWNWVTP 1:1 <br />RUSH sample <br />Other <br />Special Report Formats — ELI must be notified <br />1-01 <br />Q <br />F2 <br />F <br />a <br />submittal for <br />[r additional charges <br />C <br />C ler�� D(s) <br />to for following: <br />.- <br />w <br />prior sample submittal the <br />m <br />g <br />and schedul- <br />Custod I <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />>1 <br />o <br />� <br />g Comments: <br />Other <br />E a <br />`� <br />° <br />o <br />E <br />Intact <br />EDD/EDT E] Format <br />E SBA Schedule Code: <br />Y / <br />o <br />SW CODE 11 <br />x Table 1 <br />1= requency� 1, <br />Signature <br />Y /,!4 <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />(Name, Location, <br />Date <br />Time <br />Match BID <br />Y <br />Interval etc <br />MATRIX <br />'' <br />%" <br />' SW -AWD <br />5116113 <br />11 :40 <br />Water 1 <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />CODE 1, <br />2 SW -A001 <br />5/16/13 <br />11:50 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />Code 1 <br />3 SW BDIS <br />5/16/13 <br />12:00 <br />Water 7 <br />❑ <br />O <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Table 1 <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />5 SW OS <br />5/16/13 <br />13:05 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />11 <br />CODE 1 <br />6 SW BOS <br />5116113 <br />14:10 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Cff <br />CODE 1 <br />; <br />7 SW GS <br />5/16113 <br />14:30 <br />Water 1 <br />® <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />91 <br />CODE 1 <br />S SWBPL <br />5/16113 <br />14;40 <br />Water 1 <br />® <br />11 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />E3 <br />❑ <br />CODE 1 <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />�. <br />�o <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Date/Time:5 /16113 16:30 <br />Shipped by: FedEx <br />Received by: Dateffime: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: Datelrime:5 't <br />MUST be <br />t <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Typ2 # of fractions <br />