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COTTER CORPORATION SAMPLE SUI$MITTAL AND TRACKING FORM <br /> Sample Submittal <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. J 61/ t -S Lab. No.(s) <br /> Sample Date f t � Time 3 Date Data Entered <br /> Collected By 1 `' .r- Data Entry By <br /> Field Custodian I '. 72`2--11,r Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By i� 71'4.,?,. <br /> Received By <br /> Date Recd. 5 I 1 <br /> Time Recd. I�� <br /> 1. Sample Type: Air Water ! Soil Other (specify): <br /> 2. Analysis— Test series requested: t ; <br /> 3. Field Data—Preservation: 7' 7• �� S /' i r✓ c <br /> �, f 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 U additional attachments. <br /> QA Review: <br /> Sample valid? YES ( ) NO ( ) If NO, explain: <br /> QAC Date <br /> Page 17 o <br />