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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i y^ 527049 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. < (A11 wp Lab. No.(s) <br />Sample Date - _Z0/3TIme 1 �� <br />Collected By 1,� /1►�! G -�e <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />3. <br />l,vL�er <br />4 c to <br />vaa'uuc Lcauuowv.. <br />'7 -13 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotte <br />Z <br />!'� �. �, .ate , ._� . J T 3 <br />le) <br />rr � 1". — de <br />Sample Type: Air Water % Soil Other (specify). <br />Analysis - Test series requested: —C-70c, Q <br />1 <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( <br />QAC <br />) and explain below. <br />) NO ( ) If NO, explain: <br />Date <br />Page 7 of 8 <br />