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, <br /> COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal :,,. ,91174193 <br /> C: P.O. Box 1750 <br /> S: P.O.Box 1750 N: Box 700 <br /> Callon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. J-/ _ Lab. No.(s) <br /> Sample Date - Tlsae L S` Date Data Entered <br /> Collected By h^ Data Entry By <br /> Field Custodian ' .r c Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination J.:' f r <br /> Delivered By /mac r : Y y r /J /" f - <br /> Received By : ;' <br /> Date Recd. zDd 4. <br /> Time Recd. <br /> 1. Sample Type: Air Watery Soil Other s eci <br /> { P fy): <br /> 2. Analysis— Test series requested: f <br /> 3. Field Data—Preservation: T i ! ' I . <br /> ' i r C. 5 ,.+' 117 <br /> r <br /> 4. Date analysis required by (if not Bolding 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 18 of 20 <br />