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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal III:!- S27M <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 CaOon City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. � G-t ./ A f y_ Lab. No.(s) <br />Sample Date �' ; 21e Time <br />Collected By / C : i -. -.r .+t r % <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />�.v«�whr <br />vu -oils ues�ria`nlanan <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />t <br />is !r • /! i J flt� S <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: 7i'. <br />3. Field Data - Preservation: -T t -:�' / r ,�.�, j f° �/ � � ' T <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 ( ) and explain below. <br />COMMENTS - Explanation of noted items: <br />{ ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC Date <br />Page 26 of 26 <br />