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v <br />CD <br />CD <br />N <br />0 <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. 4593 1688 6501 <br />DATE: 6128113 SSTF: S27040 <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 -ce11 <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: POTW/WWTP E] <br />ANALYSIS <br />REQtUESTEEO <br />Notify ELI prior to <br />RUSHsample <br />Receipt <br />Other <br />f <br />submittal for <br />2 C <br />Cooler ID(s) <br />Special Report Formats — ELI must be notified <br />to for following: <br />.. <br />1m" <br />a <br />q additional charges <br />.o� <br />prior sample submittal the <br />cC <br />> 1 <br />and scheduling <br />Custody al <br />Comments: <br />NELAC [I A2LA El Level IV E) <br />m <br />i? <br />'QA1) <br />Other <br />EDD EDT ❑ Format <br />e <br />SSA Schedule Code : <br />Intact <br />7 <br />~ <br />F <br />GW CODE: <br />YIN <br />I <br />�;, <br />Signature <br />YIN <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />m <br />Z <br />a <br />F uen <br />Match LAB ID <br />(Name, Location, <br />�� <br />YIN <br />Interval, etc ) <br />MATRIX <br />' MW-7 <br />6/28/13 <br />9:15 <br />Water 6 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />�- <br />z <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />' <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />s <br />❑ <br />f ❑ 10 <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />'7 <br />❑' <br />s <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />7 <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01 <br />1= <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />0-1 <br />CO <br />s <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />0101 <br />❑ <br />❑ <br />01 <br />❑ <br />❑ <br />❑ <br />1 <br />-� <br />10 <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />(� <br />Custody <br />Relinquished : Bob Tennant Date/Time:6/28/13 <br />16:00 <br />1 Shipped <br />by: FedEx <br />Received b : Date/Time: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: DatelTime:I I �p <br />MUST be <br />Signed <br />Sample Disposal: Retum to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />