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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />` <br />Sample Submittal .._ s27153 <br />C: P.O. Box 1750 S: <br />Canon City, CO 81215 <br />Sample Loc./ID No. S ► ' " % A W <br />Sample Date 9 !O l!3 Time /Z d S <br />Collected By <br />Field Custodian O U_ e' -4n'A -r <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />4ULLCY <br />WRI- &C IMbLIMNSWU <br />y3 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />C( )-r ..1fF/ <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis – Test series requested: C—b&j <br />3. Field Data – Preservation: 1 t��- j PH 7, d10 Co -, 3.q 7 U�C�' <br />4. Date analysis required by (if not Bolding Time): _ <br />S. 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 />) and explain below. <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />Date <br />Page 13 of 13 <br />