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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal K2 5,17477 <br /> C: P.O.Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Cation City, CO$U15 Canon City, CO 81215 Nucla, CO 81424 <br /> ,,., <br /> Sample Loc./ID No. r Lab. No.(s) <br /> Sampler Date S r � �`' Time_ /.�- S +J Date Data Entered <br /> Collected By Data Entry By <br /> Field Custodian Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination j n <br /> Delivered By - <br /> Received By <br /> Date Recd. • o 4 <br /> Time Recd. I ID 15 <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis— Test series requested: <br /> 3. Field Data—Preservation: <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 22 of 23 <br />