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v <br />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No. 3692013 61723694 DATE: 5/20/13 SSTF: S26987 & S26988 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Frank Adamic 1-303 -642 -3893 mine phone <br />PO Box 1750; Canon city, CO 61215 -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 <br />ANALYSIS REQUESTED Notify ELI prior to Receipt Temp <br />Report Required For. POTW/WWTP [3 RUSH sample <br />Other a submittal for ° C <br />Special Report Formats — ELI must be notified I Yo a � additional charges Cooler ID(s) <br />prior to sample submittal for the following: o and schedulin 7 . Custody Seal <br />NELAC ❑ A2LA ❑ Level IV ❑ g o� o Comments: <br />Other <br />Y/N <br />EDD /EDT ❑ Format 1 StiA Schedule Code: Intact <br />t- GW CODE: Y/N <br />SAMPLE n � Signature <br />Y/N <br />IDENTIFICATION Collection Collection 5 a Fr uenc <br />Match LAB ID <br />(Name, Location, Date Time < Y/N <br />Interval, etc MATRIX '- <br />MW-20 5/19/13 14:00 Water 6 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ® ❑ �- <br />2 MW -9 5/20/43 14:30 Water 6 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ Z <br />3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ILU <br />• ❑ ❑ 01010 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ D 01010 <br />rr <br />❑ ❑ ❑ D ❑ ❑ ❑ ❑ D ❑ ❑ FOY CDP <br />' D ❑ D ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ oc <br />e ❑ D ❑ ❑ ❑ D ❑ ❑ ❑ ❑ —010, <br />e ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O ❑ ❑ ❑ <br />10 01010 ❑ ❑ ❑ ❑ ❑ 10 10 ❑ ❑ <br />CD <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 />Custody <br />R!! i wished by, . nt Date/Time5/20/13 14:30 <br />Shipped <br />by: FedEx <br />Received by: Date/Time: <br />Record <br />Relinquished by: DateMme: <br />Shipped by: <br />Received by: DateTime: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABOUTORY USE ONLY <br />Sample T # of fractions <br />