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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 812^ P, 15 ` Canon City, CO 81215 Nucla, CO 81424 <br />A <br />Sample Loc./ID No. -S �,/ ` !� Lab. No.(s) <br />Sample Date 'T /J� --- Time _ <br />Collected By a o % 4 f'rt �1�^ �1 t <br />Field Custodian i✓ U 6-7e;-) n- t r <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />•.viacr <br />vii -ouc Lwuua►iun <br />V <br />rL <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />ow <br />1. Sample Type: Air Water Soil (specify): <br />2. Analysis- Test series requested: =- Q <br />3. Fi Id Data - Preservation: 'c eki % .�� �--" h d Q .• J�� <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 ( ) NO( <br />CAL <br />) and explain below. <br />) If NO, explain: <br />Date <br />Page 12 of 13 <br />