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s <br /> COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal_ S ��' <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. -�' 1 Lab. No.(s) <br /> Sample Date F` f+ f r Time Date Data Entered <br /> Collected By . " +" Data Entry By <br /> Field Custodian { Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination +� f <br /> Delivered ByP T <br /> Received By f / r' J, i — <br /> Date Recd. <br /> Time Recd. 1 50 <br /> 1. Sample Type: Air Water I Soil Other(specify): <br /> 2. Analysis— Test series requested: <br /> 3. Field Data—Preservation: <br /> 4. Date analysis requir4d 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 12 of-T4 <br />