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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal Q <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. P1 Lab. No.(s) <br />Sample Date' Time % 3 Ci Date Data Entered <br />Collected By. „��� — Q— •'�i/k�+� f- _ Data Entry By <br />Field Custodian 01 ! �%r� ; } r _ Laboratory Destination if not Cotter: <br />Cotter Off -Site Destination ='7o %y l [1 r t <br />Delivered By IT �ti % f i' �i �! ✓ <br />Received By I'll ric an- <br />Date Recd. ,� y <br />Time Recd. <br />I. Sample Type: Air Water_ Soil Other (specify): <br />2. Analysis — Test series requested: i �.4 6le — <br />3. Field Data — Preservation: C— j f" '�� i t7 <br />i UA y�3 20, ' �yF <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 <br />Date <br />Page 21 of 21 <br />