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v <br />CD <br />CD <br />aN <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 61723564 <br />DATE: 6119113 SSTF: S27006 & S27007 <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 />Report Required for: POTWNW1ffP ❑ <br />�.N. <br />L���ES <br />r� =o�+ts�ren <br />Notify ELI prior to <br />RUSH sample <br />Receipt (!TT <br />o <br />Other <br />Special Report Formats — ELI must be notified <br />.. o <br />I <br />� <br />submittal for <br />a additional charges <br />--�- -` C <br />Co <br />pe ID(s} <br />prior to sample submittal for the following: <br />Em <br />~ ' <br />g <br />and scheduling <br />Custod y I <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />Comments: <br />Y <br />Other <br />EDD /EDT ❑ Format <br />< <br />E S&A Schedule Code : <br />Intact <br />z' <br />S <br />o <br />Z <br />GW CODE: <br />= <br />Y <br />Signatu�1` <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />a'm <br />Fre uenc : <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />Y/N <br />Interval, etc ) <br />MATRIX <br />� <br />MW -13 <br />6119/13 <br />12:15 <br />Water 6 <br />® <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />MW -15 <br />6 -19-13 <br />13:30 <br />Water 6 <br />® <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />D <br />D <br />D <br />❑ <br />❑ <br />❑ <br />� <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />L&A <br />° <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />D <br />D <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />... <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />D <br />❑ <br />s <br />❑ <br />❑ <br />❑ <br />D <br />0.0 <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />Ir� <br />❑ <br />❑ <br />❑ <br />D <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />s <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />D <br />D <br />❑ <br />❑ <br />D <br />D <br />❑ <br />--� <br />10 <br />❑ <br />D <br />❑ <br />D <br />10 <br />D <br />D <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Date/Time:6 /19/13 16:30 <br />Shipped <br />by: FedEx <br />Received by: Date/Time: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: Date/Time: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LA" TORY USE ONLY <br />Sample Tyl # of fractions <br />