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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal_ -- SI _ <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. rc� 42 - > Lab. No.(s) <br /> Sample Date - ~ Time t .� Date Data Entered <br /> Collected By ' ' Data Entry By <br /> Field Custodian Laboratory Destination if not Cotter:,i <br /> Cotter Off-Site Destination // r <br /> Delivered By <br /> Received By <br /> Date Recd. <br /> Time Recd. <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis— Test series requested: - <br /> 3. Field Data —Preservation: <br /> Vt <br /> LZI <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 26 of 26 <br />