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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal Nz <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. 476Y / 4-11 6 Lap.No.(s) <br /> Sample Date /'+ ` /'l Time D y5; Date Data Entered <br /> Collected By t,,11nr I x Data Entry By <br /> Field Custodian tr - Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination r z• l <br /> Delivered By ,ems q t" % <br /> Received By .� ) <br /> Date Recd. <br /> Time Recd. f <br /> 1. Sample Type: Air Water _ Soil Other (specify): <br /> 2. Analysis— Test series requested: <br /> 3. Field Data —Preservation: _y{17 s '� ?• yu� 2 6 %:. <br /> : <br /> 14 <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 /> J� <br /> QAC .� <br /> _ 1 <br /> h <br /> Panp 15 of 91 <br />