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COTTER CORPORATIRN SAMPLE. SUBMITTAL AND TRACKING FORM s <br />Sam s4mittal tlz S ZM6 <br />C: P.O. Box 1750 U S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. 4 ! .z•, ,. / <br />If <br />Sample Date Thne 1' <br />Collected By <br />Field Custodian r ' <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: ' <br />l <br />3. Field Data - Preservation: �. _ ► / ft I z {: <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 <br />Date <br />�� Page 20 of 20 <br />