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CD <br />N <br />O <br />0 <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 61723618 <br />DATE: 6=113 SSTF: S26941 <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 61215.1750 <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 t. <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: POT�IVMNIrrP El <br />ANALYSIS <br />REQUESTED <br />Notify ELI prior to <br />RUSH sample <br />ReceiTf <br />Other <br />Special Report Formats -- ELI must be notified <br />submittal for <br />additional charges <br />C <br />Coo r ID(s) <br />to for the following: <br />o 91 <br />t� <br />� <br />< <br />and scheduling <br />prior sample submittal <br />NELAC F1 A2LA [3 Level N ❑ <br />H <br />t <br />8 Comments: <br />Custody 1 <br />Other <br />EDD /EDT [I Format <br />` <br />S8A Schedub Code: <br />YI <br />Intact <br />z <br />N <br />�' <br />Z <br />�? GW CODE: <br />Y I N <br />Signature <br />YIN <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Z <br />F <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />YIN <br />Interval, etc ) <br />MATRIX <br />' SUMP-5 <br />6/06113 <br />9:40 <br />water 6 <br />® <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />y- <br />2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Z io <br />3 <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />W <br />4 <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 <br />oro k�a <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />r <br />' <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />e <br />❑ <br />❑ <br />a <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />0.0.0.0 <br />tm <br />e <br />O <br />D <br />❑ <br />D <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />-� <br />to <br />❑ <br />❑ <br />010113 <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />Custody <br />RefinqWshed T n n Date/Time:6 MI3 17:00 <br />1 Shipped <br />by: FedEx <br />Received by: Date/Time: <br />Record <br />Reftquished try: Date/Time: <br />I Shipped by: <br />Received by: e/Time: _ <br />MUST be <br />Signed <br />Sample Olsposal: Retum to Client ❑ Lab Disposal <br />LABO TORY USE ONLY <br />Sample T # of fractions <br />