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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ":2' <br />S27668 <br />C: F A Box 1750 S:. P.O.. Box 1750 N:. P.O. Boa 700 <br />Canon City, CO 81215 Ca#ion City, CO 81215 Nucla, CO 81424 <br />SamalalwAD N6. _ �� G v f Lab. No.(s) <br />SalQte 4 Time <br />Colec y <br />Fb <br />�r_, <br />Received By <br />Time Recd. r • Gil <br />1. �idpli'ljrple -Air <br />2. ; �' _ Test se�ii <br />.�r . <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />r« / <br />Water l-1~ Soil Other (specify): <br />ted: n- -4& <br />3. Field Data - Preservation: 41- : j ? <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 <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO <br />QAC <br />) and explain below. <br />) If NO, explain: <br />Date <br />Page 7 of 8 <br />