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CD <br />CD <br />N <br />N <br />0 <br />A <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 1 <br />Company Name: Cotter Corporation <br />Project Name: Schti riz - <br />Tracking No. 4593 1687 8054 <br />DATE: 5118/13 SSTF: S26985 & S26986 <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: POTW/WWTP El <br />ANALYSIS <br />REQUEST <br />"o <br />No ELI to <br />RUSH sampler <br />Receigg <br />Other <br />submittal for <br />V 1.0 0C <br />Special Report Formats — ELI must be notified <br />o <br />Q additional charges <br />Co,Qler ID <br />prior to sample submittal for the follovAng: <br />Fly - <br />� <br />and scheduling <br />ii.� <br />NELAC ❑ A2LA E] Level IV ❑ <br />Other <br />3 <br />Q <br />Custody eaI <br />Y N <br />Intact <br />g <br />Comments: <br />EDD/EDT ❑ Format <br />SBA Schedule Code : <br />Z <br />N <br />z <br />GW CODE: <br />Y 1 <br />Signature <br />Y / <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Colkx*w <br />F uen <br />Match IJ B ID <br />(Name, Location, <br />Date <br />Time <br />Interval, etc ) <br />MATRIX <br />w <br />a <br />Y <br />MW -12 <br />5/18/13 <br />11:05 <br />Water 6 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />�- <br />2 MW-19 <br />5118/13 <br />12:30 <br />Water 6 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />Z <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />uJ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />�I <br />s <br />01010 <br />❑ <br />❑ <br />❑ <br />CI <br />❑ <br />❑ <br />❑ <br />❑ <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑.- <br />' <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />8 <br />❑ <br />❑ <br />❑ <br />13 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />W <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />1010.0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />' <br />Custody <br />Reli fished Ten nt DateJTime5118/13 <br />14:30 <br />1 Shipped <br />by: <br />FedEx <br />Received by: Date/Time: <br />Record <br />Relinquished by: Date/Time: <br />I Shipped by: <br />Received by: Da te/Time: <br />MUST be <br />Signed <br />Sample Disposal: Retum to Client ❑ Lab Disposal 0 <br />LABO TORY USE ONLY <br />Sample Type # of fractions <br />