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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal MOD <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Callon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br /> 11 <br /> Sample Loc./ID No. r" r `, <br /> ..� Lab. No.(s) <br /> Sample Date r -� '` Time / S <br /> -Lj'L Date Data Entered <br /> Collected By ., '. ' , , <br /> Data Entry By <br /> Field Custodian - ', f - -" Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination r. <br /> Delivered By- .. <br /> Received By <br /> Date Reed. <br /> Time Reed. <br /> } r <br /> I. Sample Type: Air Water / Soil <br /> Other (specify): <br /> 2. Analysis - Test series requested: <br /> 3. Field Data-Preservation: Z1.�• i :' T• /� �j/ <br /> V Pr <:1 5 f-'/tr r7 <br /> lk <br /> F <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 13 of 15 <br />