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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> 'Sample Submittal .." s!7s u3 <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. _a (' '� Lab. No.(s) <br /> Sample Date ` `� �� Time D ' %�' Date Data Entered <br /> Collected By r ° " • ,"7 'r Data Entry By <br /> Field Custodian f'r ` ," v , r ^ _r Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By -- —7 <br /> Received By <br /> Date Recd. <br /> Time Recd. /Type: ( <br /> 1. Sample e• Air Water �_ Soil Other (specify): <br /> 2. Analysis— Test series requested: <br /> t 20 , <br /> 3. Field Data—Preservation: <br /> t " r. ' - <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 /> -- .. - Pagel 5 of 16 <br />