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I 1 y <br /> COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal s2al <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 LocJID No. �✓ " J Lab. No.(s) <br /> Sample Date S' • 2 2 - Time . 4 5~ Date Data Entered <br /> Collected By >t'i - %.�.� c -, '` Data Entry By <br /> Field Custodian Ir., X nEs., c Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination c so 1 c 4 0,e c f�• � � . c <br /> Delivered By r" ".��. 1 f� Z `� . �f ("7r <br /> Received By ��a .. `r is v�t�.- �: � c o / <br /> -f <br /> Date Recd. <br /> Time Recd. I PIP <br /> �.. <br /> 1. Sample Type: Air Water #_ Soil Other (specify): <br /> 2. Analysis- Test series requested:� �i'le <br /> 3. Field Data-Preservation: 7e fl A. C <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 23 of 24 <br />