2013-08-20_HYDROLOGY - M1977300 (4)

Home Browse Search

v CD CD N 0 N W Chain of Custody and Analytical Request Record PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page .1 of 1 Company Name. Cotter Corporation Project Name: Schwartz - Trac king No. 3692013 61723567 DATE: 6/20/13 SSTF: S27008 & S27009 Report Mail Address: Sampler Name if other than Contact: Cotter Corporation - Canon City Mill Contact Name: Frank Adamic 1- 303-642 -3893 mine phone PO Box 1750; Canon City, CO 81215 -1750 Voice: 1- 719 -275 -7413 ext. 204 Bob Tennant 1 -719 -371- 3009 -Cell Invoice Address: Invoice Contact: JoAnne Ary Purchase Order #: ELI Quote #: PO Box 1750 Tel: 1- 719 - 275 -7413 ext. 209 Canon City, CO 81215 -1750 Fax: 1- 719- 275 -16ti9 Report Required For. POTW/WWTP ❑ ANALYSIS REQUESTED Notify ELI prior to RUSH sample Receipt T� Other l= submittal for r I C C ler ID(s) Special Report Formats – ELI must be notified .. o II! �m Q F additional charges prior to sample submittal for the following: ~ t and scheduling Custod/ ❑ A2LA ❑ Level IV ❑ ms v', o Comments: Neal ��C rm EDD /EDT ❑ Format `� a ; SM Schedule Code: Intact z F- 0 GW CODE: � Y / N Signature YJN SAMPLE IDENTIFICATION Collection Collection z x F uen Match LAB ID (Name, Location, Date Time < Y / N Interval, etc)__ MATRIX '" a MW- 17 6/20113 11:15 Water 6 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ �- z MW-18 6120113 13:20 Water 6 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ �~ s ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ UJI 01010 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ �► 5 01010 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ g 01010 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ �— 7 ❑ ❑ ❑ ❑ ❑ ❑ 01010 ❑ ❑ ❑ Cr. e ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ �I e ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ J io ❑ 010,010 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Custody Relinquished Ten a Datefrime:6/20 11316:00 Shipped by: FedEx Received b : DateTme: Record Relinquished by: Date/ Time: Shipped by: Received by: Daterrime: _ MUST be Signed Sample Disposal: Retum to Client ❑ Lab Disposal ® LABORATORY USE ONLY Sample Type # of fractions