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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 />Company Name: Cotter Corporation <br />Project Name: Schwartz - <br />Tracking No. 3692013 61723656 <br />DATE: 5/23113 SSTF: S26999 & S27000 <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 />ANALYSIS <br />REQUEST <br />T 60 <br />Notify ELI prior to <br />Receipt Temp <br />Report Required For: POTW/WWTP C] <br />RUSH sample <br />z o C <br />Other <br />Special Report Formats —ELI must be notified <br />to sample submittal for the following: <br />V <br />E <br />a <br />"Submittal for <br />p additional charges <br />t and scheduling <br />ler ID s <br />prior <br />>' <br />Custod I <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />Other <br />a w <br />_ <br />$ Comments: <br />Y <br />EDD /EDT ❑Format <br />a <br />-E <br />S&A <br />A Schedule Code : <br />Intact <br />x >v <br />1 <br />� GW CODE: <br />YIN <br />Signature <br />YIN <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />� <br />z <br />Fre uenc : <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />YIN <br />Interval, etc) <br />MATRIX <br />WW-2 <br />5/23!13 <br />10:54 <br />Water 8 <br />IN <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />Oki <br />❑ <br />�- <br />2 MW -1 <br />5!23113 <br />13:50 <br />Water 6 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />011310 <br />® <br />❑ <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />ILU <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o <br />s <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 />CP <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />cc <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />-.1 <br />,o <br />[:]10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />Custody <br />Relinquished : Bob Tennant Date/Time5/23/13 <br />14:30 <br />Shi <br />by: FedEx <br />Received by: Date/Time: <br />Record <br />Relinquished by: Daterrime: <br />Shipped by: <br />Received Date/Time: rio <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LA80F,4TORY USE ONLY <br />Sam le T # of fractions <br />