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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal <br /> x* <br /> C: P.O. Box 1750 S: P.O.Box_1750 N: P.O.Box 700 <br /> Cason City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. r->�' /I ?' /-;) Lab. No.(s) <br /> Sample Date I Ll Time J d Date Data Entered <br /> Collected By _% ` 4 A %' Data Entry By <br /> Field Custodian ' , a `" } Laboratory Destination if not Cotter: <br /> Cotter OH-Site Destination .. t} f. <br /> Delivered By <br /> Received By <br /> Date Recd. C ' <br /> Time Recd. r <br /> 1. Sample Type: Air Water �_ Soil Other (specify): <br /> 2. Analysis — Test series requested: �' I <br /> 3. Field Data—Preservation: 1r 7. � r 7 c `' <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 />