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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal 5"4174 <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. C6t.,I's 1>4 . Lab. No.(s) <br /> Sample Date S' S`�" /41 Time_ ��• ? i� Date Data Entered <br /> Collected By Date�+ �'� " Data Entry By <br /> Field Custodian ff:, 1; t r��p is c - Laboratory Destination if not Cotter: <br /> Cotter Ott-Site Destination <br /> Delivered By <br /> Received Bys k-, / <br /> Date Recd. <br /> Time Recd. .•�, <br /> 1. Sample Type: Air Water 1 Soil Other (specify): <br /> 2. Analysis— Test series requested:( I c--!0 f <br /> 3. Field Data— Preservation: " I > H�� . ! 7 <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 33 of 35 <br />