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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ! ''" 1 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Canon City, CO 81215 Caiion City, CO 81215 N. P.O. Box 700 <br />Nucla, CO 81424 <br />Sample Loc./ID No. C, `y^ <br />Sample Date - - ! Time D <br />Collected By <br />Field Custodian I <br />Delivered By / _ .,7 n e <br />Received By f' P V <br />Date Recd. • <br />Time Recd. f /: co <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />1. Sample Type: Air Water ,L) Soil <br />Other (specify): <br />2. Analysis - Test series requested: 77 /, 2 <br />3. <br />4. <br />S. <br />Field Data - Preservatio �nG <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other Instructions: <br />6. Invalidating circumstances? If YES Initial <br />COMMENTS - Explanation of noted items: <br />L7 /5.4_q <br />) and explain below. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( } If NO, explain: <br />QAC <br />Date <br />_c <br />Page 30 of 31 <br />