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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal S DIMS <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Caiion City, CO 81215 Nucla,CO 81424 <br /> Sample Loc./ID No. Ali,/ 3 Lab. No.(s) <br /> Sample Date ' '7 r' /"' Time 11 3 0 Date Data Entered <br /> Collected By I`.- ° -r - -. Data Entry By <br /> Field Custodian Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By =' <br /> Received By <br /> Date Reed. <br /> Time Reed. <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis- Test series requested: 2- <br /> 3. Field Data-Preservation: Tot- �Z � r�� � O Z/ � �:'' S 40 � <br /> p'/qt�t , : �, �t• �.• ., G 74/ /1. V .. �3 v c.• C' 0. S' i l�r.•1 <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? Y8S ( ) NO ( ) If NO, explain: <br /> QAC Date <br /> Page 24 of 24 <br />