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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal <br /> C: P.O. Box 1750 S: P.O.Box 1750 <br /> Canon City,CO 81215 Callon City, CO 81215 N: P.O.Box 700 <br /> Nucla, CO 81424 <br /> Sample LocJID No. pl K" <br /> Lab. No.(s) <br /> Sample Date �� Time ? ? Date Data Entered <br /> Collected By - t. <br /> Data Entry By <br /> Field Custodian <br /> Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination ,. <br /> Delivered By 4 . - <br /> Received By <br /> Date Recd. r <br /> Time Recd. <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis— Test series requested: <br /> 3. Field Data—Preservation: f / <br /> r <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, explainf'� <br /> QAC Date ' C: <br /> Page 13 of 13 <br />