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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKJG FORM <br /> Sample Submittal -�. <br /> C: P.O.Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Ca0on City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. 00^_1 p Lab. No.(s) <br /> Sample Date 7 '% 4 L'yj� Tie r /�'n 7 Date Data Entered <br /> Collected By �� J Pn h f _ Data Entry By <br /> Field Custodian 17 ? l-4 r 4 � Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By <br /> Received By <br /> Date Recd. <br /> Time Recd. at7- ; <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis — Test series requested: r - <br /> 3. Field Data—Preservat' n: <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, explain: <br /> QAC Date <br /> Page 22 of 22 <br />