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v <br />CD <br />CD <br />N <br />0 <br />a <br />N <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: Schwartz - <br />Tracking No. 3692013 61723344 <br />DATE: 4111/13 SSTF: S26889 <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 />ANAL <br />r. =t, <br />ftr_(tt3E <br />STUD <br />Notify ELI prior to <br />Receipt Temp <br />Report Required For: POTWN ifTP E] <br />RUSHsample <br />C <br />Other <br />„, <br />P <br />submittal for <br />ID <br />Special Report Formats - ELI must be notified <br />..OR <br />G <br />a additional charges <br />Soler <br />�) <br />prior to sample submittal for the following, <br />NELAC [I A2LA ❑ Level IV ❑ <br />~ 0.� <br />Q <br />and scheduling <br />Custody Seal <br />Comments: <br />Other <br />Z y <br />Y/N <br />EDD /EDT E] Format <br />9 a <br />3 <br />E <br />S&A Schedule Code: <br />Intact <br />E <br />x'001 <br />r <br />€ <br />Z <br />co <br />GW CODE: <br />Y / N <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Fre uen <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />Y / N <br />Interval, etc ) <br />MATRIX <br />e <br />RAIN 19 <br />4/11/13 <br />11:00 <br />Water 6 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />tore <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />rAhQ <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />;. <br />' <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />9 <br />❑ <br />010,010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />,» <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished : Bob Tennant Date/Time:4 /12/13 16:30 <br />Shipped <br />by: FedEx <br />Received by: Date/Time: <br />Record <br />Relinquished by: Datelrime: <br />Shipped by: <br />Received by: "jet Date/Time: -15-13 9 <br />MUST be <br />Signed <br />Sample Disposal: Return to Client [] Lab Disposal ® <br />LABORATORY USE ONLY <br />Sam Ie Type # of fractions <br />T <br />