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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal 5466 <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Cation City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. Isl•.� ' � t Lab. No.(s) <br /> Sample Date `If • "1 I" ';/Y Time Y=± '? Date Data Entered <br /> Collected By 19 Data Entry By <br /> Field 66todian r'.. Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination ., N f ;F ! < <br /> Delivered By71 <br /> fa <br /> Received By <br /> Date Reed. y NO- <br /> Time Reed. t �' <br /> r . <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis- Test series requested: ' 1 <br /> 3. Field Data-Preservation: <br /> � r T <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 25 of 26 <br />