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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal 1!i-' S z7#7 <br /> C: P.O.Boa 1750 S: P.O.Box 1750 N: P.O.Box 700 <br /> Caifon City,CO 81215 Callon City,CO 81215 Nucla,CO 81424 <br /> Sample LocAD No. f6f-'f A Lab.No.(s) <br /> Sample Date I0 - y Time Qd Date Data Entered <br /> Collected By Data Entry By <br /> Field Custodian 'j :.r r- R # Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By ' <br /> Received By �~ _ l-tl f l' o f <br /> Date Recd. <br /> Time Recd. /6 <br /> 1. Sample Type: Air Water Soil Other(specify): <br /> 2. Analysis- Test series requested: T <br /> 3. Field Data-Preservation: 7r to. 1 7 4 <br /> ii f1 <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 /> Papa M of 7d <br />