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COTTER CORPORATION SAMPLE SUSeijLfTAL AND TRACKING FORM <br />Sample Submittal r al.0-11 S 17 "1 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. �✓ ' y Lab. No.(s) <br />Sample Date Q# " "y Time /� Y <br />Collected By 1"�3 AZ _ ► y <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.v�a� <br />wa -aunt aicsa�asava <br />?r <br />fr� <br />` <br />��__. Soil <br />Other (specify): <br />2. Analysis - Test series requested: <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />per._ v Lr. �►. ! % c.. <br />z 311 <br />,� <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />6. Invalidating circumstances? I[ 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 f Date <br />Page 24 of 25 <br />1. Sample Type: Air <br />Water <br />��__. Soil <br />Other (specify): <br />2. Analysis - Test series requested: <br />3. Field Data - Preservation:r <br />,l <br />7 <br />r <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />6. Invalidating circumstances? I[ 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 f Date <br />Page 24 of 25 <br />