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v <br />N <br />a <br />W <br />ANWChain 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 61723687 <br />DATE:5 /21/13 SSTF: S26991 TH S26995 <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 />F .. <br />Air <br />ALYSSS <br />R!EQUFSTf-,o <br />Notify ELI prior to <br />Receipt Temp <br />Report Required For. POTW/W111r•rP ❑ <br />RUSH sample <br />Q <br />Other <br />o <br />a <br />submittal for <br />eri - ID ) <br />Special Report Formats - ELI must be notified <br />.. <br />a <br />F additional charges <br />�1` <br />prior to sample submittal for the following: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />Pea <br />$ <br />and schedulin <br />"S Comments: <br />Cusbody�l <br />�', <br />3 <br />o <br />Q <br />Other <br />EDD /EDT ❑ Format <br />`� Q� <br />o <br />Schedule Code: <br />Intact <br />SW Cd <br />i <br />YIN <br />Rif <br />_ <br />x Table 1 <br />Frequency) 1, <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Match LAB ID <br />(Name, Location, <br />Date <br />77me <br />YIN <br />Interval, etc <br />MATRIX <br />~ <br />i SW -AWD <br />5/21/13 <br />10:45 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />CODE 1 <br />>. <br />2 SW-A001 <br />5/21/13 <br />10:55 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />CODE 1 <br />Ewa <br />3 SW BDIS <br />5121113 <br />11:35 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />CODE 1 <br />LU <br />4 SW PL <br />5121/13 <br />11:45 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />CODE 1 <br />5 SW OS <br />5/21/13 <br />12:30 <br />Water 7 <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />jig <br />❑ <br />TABLE 1 <br />� <br />❑ <br />1 ❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />"ISO h <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />tact <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />.-.r <br />F— - —t— <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ 10 <br />LO <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Datetrime:4/21/1316:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: TH- Date/Time: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />R <br />i Fl <br />