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v <br />CD <br />CD <br />41 <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 6317 <br />DATE: 6/04113 SSTF: S26937 <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 POTWNVWTP ❑ <br />QNi,Az¢ <br />YSB`4+ <br />REQUESTED <br />Notify ELI prior to <br />RUSH sample <br />Receipt /T mp <br />a <br />Other <br />Special Report Formats - ELI must be. notified <br />e <br />2.01 <br />F <br />a <br />submittal for <br />i= additional charges <br />`I C <br />C ler ID(s) <br />to sample submittal for the followng <br />C and <br />prior :'� <br />scheduling' <br />Custody I <br />NELAC E] A2LA E] Level IV El <br />Owl <br />_ <br />12 Comments: <br />Other <br />a <br />Q <br />Y/ <br />Intact <br />EDD /EDT E] Format <br />`fi r <br />_ <br />S&A Schedule Code . <br />Y CN ) <br />z <br />�' <br />€ <br />Z <br />GW CODE: <br />= <br />/ <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Fre uen <br />Match ID <br />(Name, Location, <br />Date <br />Time <br />Y I N <br />Interval, etc) <br />MATRIX <br />. <br />1 Mine Refill <br />6/(W13 <br />9:45 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />1 ❑ <br />❑ <br />❑ <br />FIR <br />❑ <br />Total Organic Carbon <br />2 <br />❑ <br />❑ <br />❑ <br />CI <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />` <br />❑ <br />❑ <br />❑ <br />111010 <br />❑ <br />O <br />❑ <br />❑ <br />01 <br />❑ <br />s <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />6 <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />tl"" <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />11 <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />E00 <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by-, Bob Tennant Date/7ime6 /04/1314:30 <br />Shipp <br />b : 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 0 <br />LAB TORY USE ONLY <br />Sam !e T # of fractions <br />0 <br />