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r � � <br /> 1 <br /> COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal ZL S274" <br /> C: P.O.Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, COyww Callon City, CO 81215 Nucla, CO 81424 <br /> Sample LocJID No. A Lab. No.(s) <br /> Sample Date 1' Time f 3`} Date Data Entered <br /> Collected By Data Entry By <br /> Field Custodian '`� '` 1 Laboratory Destination if not Cotter: <br /> ! r <br /> Cotter Off-Site Destination � V I , <br /> Delivered By <br /> Received By <br /> Date Recd. <br /> Time Recd. �' 1 <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis— Test series requested: <br /> 3. Field Data—Preservation: 7 <br /> 7 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 /> r <br /> Page 23 of 23 <br />