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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Ejample Submittal ► ' S V44S <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. �� Lab. No.(s) <br /> Sample Date Time 1&47'41 Date Data Entered <br /> Collected By '_` .` Data Entry By <br /> Field Custodian r' 1 Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By <br /> Received By f"" 1..:x .,� �_.�._,`, _ t - _ �, 7 / <br /> Date Reed. <br /> Time Reed. <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis— Test series requested: <br /> 3. Field Data—Preservation: f <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 Date <br /> Page 20 of 20 <br />