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CD <br />CD <br />0 <br />N <br />N <br />AMU 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 61723571 <br />DATE: 6118/13 SSTF: S27005 <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 />AHAGV <br />SiS <br />REQUESTED <br />Notify ELI prior to <br />Rece' p <br />Report Required For: POTWANWTP ❑ <br />RUSH sample <br />�trpm <br />Othe r <br />Special Report Formats -ELI must be notified <br />.. <br />>i <br />F <br />submittal for <br />F additional charges <br />' C <br />Cf!r tD s) <br />prior to sample submittal for the following: <br />NELAC ❑ A21-A ❑ Level IV ❑ <br />tm <br />~' <br />and schedulin <br />Comments: <br />us <br />Ctody eal <br />Othe <br />Y <br />EDD /EDT El Format <br />i <br />E SBA Schedule Code: <br />Intact <br />z <br />I� <br />N <br />a <br />GW CODE: <br />Y / N <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />aril <br />oc F u nn <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />Y / N <br />Interval, etc) <br />MATRIX <br />MW -19 <br />6/18/13 <br />13:00 <br />Water 6 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />y- <br />2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />3 <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />W <br />4 <br />01010 <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />B <br />❑ <br />❑ <br />D <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />i}-- <br />1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />g <br />❑ <br />❑ <br />D <br />❑ <br />010101010 <br />❑ <br />❑ <br />❑ <br />-� <br />ID <br />❑ <br />❑ <br />❑ <br />❑ <br />01[:1101010 <br />❑ <br />❑ <br />❑ <br />Custody <br />Reunquished Bob Tennant Date/Time:6118/13 17:00 <br />1 Shipped <br />by: FedEx <br />Received by: Date/Time: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: -Pf DatetTime: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />'Sample Type # of fractions <br />9 <br />