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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal _ *`L S M I I <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. — Q Lab. No.(s) <br /> Sample Date .c, Zj � Time Date Data Entered <br /> Collected By A,4 Jz r',s.wi c n I Data Entry By <br /> Field Custodian /T o 4 Laboratory Destination if not <br /> Cotter: / <br /> Cotter Off-Site Destination C" s <br /> Delivered By j=� r: -�'� !'' � ,� 3 :i c Coo- F F �. ..,. <br /> Received By �' r �("r -- r�� f�>= Y lt/ ?� ?' t `' <br /> Date Recd. <br /> Time Recd. + <br /> I. Sample Type: Air Water C'' 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 t <br /> Page 21 of 21 <br />