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COTTER CORP"ATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sagfple �obmittal s.: <br />C: P.O. Boa 1750 S: P.O. Box 1750 N: P.O. Boa 700 <br />Canon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. cwt/ P—Al== Lab. No.(s) <br />Sample Date ? rev Date Data Entered <br />Collected By /1:► S Data Entry B� <br />y <br />Field Custodian _/�. �, �'�v n .. ' Laboratory Destination if not Cotter: <br />Cotter Off-Site Destination <br />Delivered By ' - T -^ Y <br />Received By---r <br />Date Recd. <br />Time Recd. <br />4 <br />1. Sample Type: Air Water Soil Other (specify): �- <br />2. Analysis - Test series requested: %r I <br />3. Field Data -Preservation: "L. /N. 3 , 1 ! f_ 17. % t y y .,� , " , , •e <br />7. y2, i, c Ir^ r- / -/ c? ILI <br />4. Date analysis required by (if not 13p1ding' time): <br />S. Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial ( ) and explain belov. <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 28 of 29 <br />