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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Subms tal <br /> C: P.O. Box 1150 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#^ f � , J� Lab. No.(s) <br /> Sample Date 57' 2 2 ' f Y Time b 5 Date Data Entered <br /> Collected By ►� '� n���^ r Data Entry By <br /> Field Custodian �f'" T+ Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination Y_^,c'.e� Y `• - ` r ` �-- <br /> Delivered By <br /> r <br /> Received By f .,F �f-r Cc sr..� <br /> Date Reed. ' <br /> Time Recd. <br /> 1. Sample Type: Air Water `(.. Soil Other (specify): <br /> 2. Analysis — Test series requested:Lrd h''` ' <br /> 3. Field Data—Preservation: 1 , - ''`� � ��• -. ,, <br /> .. <br /> 4. 11te analysis required by (if not Holding Time): <br /> 5. !j�pecial handling conditions or other instructions: <br /> 6. Inv�lidil log circumstances? If YES11iAtial ( } and explain below. <br /> COMMEP 15-Explanation of noted items: <br /> ( ) Check if a$ditio l attachments. <br /> QA Re <br /> S valid? YES { ) "NO ( ) If NO,explain: <br /> QAC Date <br /> Page 24 of 24 <br />