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I <br />c� <br />AZU 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 I <br />Company Name: Cotter Corporation <br />Project Name: Schwalm - <br />Tracking No. 45931688 6339 <br />DATE: 6/13/13 SSTF: $27035'5 <br />Report Mail Address: <br />Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill <br />Contact Name: Frank Adamic <br />1- 303 - 642 -3893 mine phone <br />PO Box 1750; Canon City, CO 81215 -1750 <br />Voice: 1- 719 -275 -7413 ext. 204 <br />Bob Tennant 1- 719- 371 - 3009 -cell <br />Invoice Address: <br />Invoice Contact: JoAnne Ary <br />Purchase Order #: <br />ELI Quote #: <br />PO Box 1750 <br />Tel: 1- 719 - 275 -7413 ext. 209 <br />Canon City, CO 81215 -1750 <br />Fax: 1- 719 -275 -1669 <br />ANALYSIS <br />REQUESTED <br />Notify ELI prior to <br />Receipt Temp <br />Report Required For: POTWWWTP ❑ <br />RUSH sample <br />Q, 4 , C <br />Other — <br />Special Report Formats — ELI must be notified <br />Vol l <br />� <br />� <br />submittal for <br />a additional charges <br />r IDI ,$) <br />`7 <br />prior to sample submittal for the following: <br />NELAC C] A&A El Level IV ❑ <br />Fpm <br />y <br />c <br />- <br />t and scheduling <br />Comments: <br />CustoYdy I <br />>s <br />EDD/EDT [:1 Format <br />E S&A Schedule Code : <br />intact <br />p <br />r- <br />z <br />�? GW CODE <br />Frequency: <br />Y / N <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />o: <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />Y i N <br />Interval etc <br />MATRIX <br />`" <br />a <br />Mine Refill <br />6/13113 <br />9:30 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />D <br />❑ <br />❑ <br />® <br />❑ <br />Z <br />❑ <br />❑ <br />❑ <br />❑ <br />r-3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />3 <br />01010 <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />s <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />li-- <br />' <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />$ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />m <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />—� <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished q: Bob Tennant Datetrime:6/13/13 12:00 <br />LShipped <br />by: FedEx <br />Received b <br />ime: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: eIme: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />I ABORATIORY USE ONLY <br />gym, Ie T # of fractions <br />