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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />IL <br />Sample Submittal 29 S <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Capon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. , L f Lab. No.(s) <br />Sample Date 1 Time _ 7 <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />l.V«Cl <br />Vll'OILG I/�a L1W1LLVY <br />Z- <br />1� <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />� J <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: <br />+$ r ^3 � r <br />3. Field Data - Preservation: i r Z 72 y ' '160 <br />r 1. '7 4- j_ } Ftr l.r e--:- <br />4. <br />5. <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />b. 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 Date <br />Page 9 of 10 <br />