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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal L S276,63 <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 LocJID No. Ana A V7 1 // Lab. No.(s) <br />Sample Date P) Time OJ <br />Collected By <br />Field Custodian . d3 r .r rr r_ . t <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />\.VLLCK <br />Vil -019C I/CbLInnuum <br />% <br />r, %jr <br />7 -I <br />�3 <br />h <br />F Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />i <br />y <br />Sample Type: Air Water Soil <br />Analysis- Test series requested: <br />N <br />Other (specify): <br />3. Field Data - Preservation: [= 16' � ; ' ! % � r l i� S � , _ � , - , r_ <br />` ; �- , 7 � � - { { • f ,u �3� � s...........,�+f� ':I� %Cr:'�l� ? 1'L _ 1 .� ,f G .L.. ; <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 Date <br />Page 13 of 13 <br />