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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal S"S48 <br /> C: P.O. Box 1750 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.1ID No. JJt�+ ^^ ! " Lab. No.(s) <br /> Sample Date - 3`' Time `� Date Data Entered <br /> Collected By >.' 174 n Data Entry By <br /> Field Custodian ! :E. I -t f ^ '� _- Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By <br /> Received By <br /> Date Reed. 1a1, I f4 <br /> Time Reed. OS <br /> 1 , r <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis- Test series requested: f,-, -4 / ✓Z-- <br /> 3. Field Data-Preservation: •j 4" <br /> 4. Date analysis required by (if not Holding Time): <br /> S. 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 Da4 <br /> Page 21 of 21 <br />