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COTTER CORPORATION SAMPLE SUBMITTAL 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 Callon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. -7 4tl /�.� Lab. No.(s) <br /> Sample Date �� .� j `` Time Date Data Entered <br /> Collected By r's„ , r. t Data Entry By <br /> Field Custodian 'I", ,, 1., ,4 ,« � T Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination Ar <br /> Delivered By i L f T 11-1-Cr„71 <br /> Received By <br /> Date Recd. <br /> Time Recd. <br /> 1. Sample Type: Air Water J r. Soil Other (specify): <br /> 2. Analysis- Test series requested: _ <br /> 3. Field Data- Preservation: a C 1 tt `l <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 10 of 15 <br />