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v <br />CD <br />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No. 3692013 61723359 DATE: 5/15/13 SSTF: S26920 & S26921 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Frank Adamic 1- 303 - 842 -3893 mine phone <br />PO Box 1750, Canon City, CO 81215 -1750 Voice: 1- 719 -275 -7413 ext. 204 Bob Tennant 1 -719- 371 - 3009 -cell <br />Invoice Address: Invoice Contact JoAnne Ary Purchase Order #: ELI Quote #: <br />PO Box 1750 Tel: 1- 719 -275 -7413 ext. 209 <br />Canon City, CO 81215 -1750 Fax: 1 -719- 275 -1669 C <br />ANALYSIS REQUESTED Notify ELI prior to <br />D, �p <br />Report Required ForForPOTWNVWTP ❑ RUSK sample Receipt <br />Other submittal for o C <br />Special Report Formats — ELI must be notified o additional charges r ID s) <br />prior to sample submittal for the following: M t✓ and scheduling <br />NELAC ❑ A2LA ❑ Level IV ❑ Custody gal <br />3 g Comments: <br />Y <br />Other 3 E <br />EDD /EDT E] Format � S&A Schedule Code: Intact <br />Z F GW CODE: Y/N <br />SAMPLE 0 x Signature ,$' z ` Y/N <br />IDENTIFICATION Collecti� Collection ej � <br />(Name, Location, Date Time F uenc : Match LAB ID <br />Interval, etc MATRIX <br />w Y/N <br />MW 13 5115/13 16:26 Water 6 IS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ yR <br />2 MW 15 5/15/13 14:00 Water 6 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br />3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ W <br />4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />S ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />e <br />010,0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ !- <br />' ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />e ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ m <br />g ❑ ❑ ❑ ❑ ❑ 01010.0 ❑ ❑ ❑ --s <br />40 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ <br />CD <br />AMUChain 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 />Custody <br />Relinquished by: Bob Tennant DatafTime5 <br />/1611314:30 <br />Shi <br />by: FedEx <br />Received by- DaWrime: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: fiaterrime: <br />MUST be <br />Signed <br />Sample Disposal: Retum to Client ❑ tab Disposal 0 <br />LABOlfjAORY USE ONLY <br />Sample Type <br /># of fractions <br />