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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ": -' S a 15 5 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: <br />Canon City, CO 812155 Canon City, CO 81215 <br />j <br />Sample Loc./ID No. � "I C B R r v Lab. No. (s) <br />Sample Date 9-/O-/J Time <br />Collected By & U 6 <br />Field Custodian 22 v � P <br />Delivered By <br />Received By <br />Date Recd. <br />c-. <br />c�l r:--, X <br />Date Data Entered <br />Data Entry By <br />P.O. Box 700 <br />Nucla, CO 81424 <br />Laboratory Destination if not Cotter: ! <br />Time Recd. <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested ,/- <br />Field Data - Preservation: { <-•' 14q. 7 V t j -7. 5+ ;L C uno I l a <br />1.00 16. PAH <br />L U F 4 vi k/01 t0.-.1 <br />4. Date analysis required by (if not Holding Time): <br />S. 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 11 of 13 <br />