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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal } 3 <br />x 1750 <br />S: P.O. Box 1750 N: P.O. Box 700 <br />fo <br />• Cadon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No.. L L oV Lab. No. {s) <br />Sample Date 8 "7-'2 0/3 Time lip Date Data Entered <br />Collected By ,'°'? Data Entry By <br />Field Custodian 1 <br />�� ,,r Laboratory Destination if not Cotter: <br />Cotter Off -Site Destination <br />f-= 7..C.T, �r� C <br />Delivered By'h <br />Received By c` �'� " 6V <br />Date Recd. <br />Time Recd. r <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis — Test series requested: el x" /r' <br />Ode S: t/ 9 r 5 - -r UL. <br />3. Field Data — Preservation: ��� <br />Cr ti0' ?.Z� y "mot (7 <br />5. <br />Date analysis required by (if not Holding Time): _ <br />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 ( ) NO ( <br />) and explain below. <br />) If NO, explain: <br />QAC Date <br />