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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal _ i L St"1 a <br /> C: P.O. Boa 1750 S: P.O.Box 1750 N: P.O.Box 700 <br /> Canon City,CO 81215 Cation City,CO 81215 Nucla,CO 81424 <br /> Sample Loc./ID No. �� !S, Lab.No.(s) <br /> Sample Date /d -$ - 161 Time Date Data Entered <br /> Collected By �` I % %�'r•�,�ty Data Entry By <br /> Field Custodian e, ., Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination Z` ,4 Co* r u, Z. <br /> Delivered By <br /> Received By <br /> Date Reed. 1 1 <br /> Time Reed. Ck �9, r <br /> 1. Sample Type: Air Water Soil Other(specify): <br /> 2. Analysis- Test series requested: <br /> 3. Field Data-Preservation: <br /> 4 <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 ( ) and explain below. <br /> COMMENTS-Explanation of noted items: <br /> ( ) Check if additional attachments. <br /> QA Review: <br /> Sample valid? YES( ) NO( )a If NO,explain: <br /> QAC Date <br /> rt <br /> P20P.8 of 8 <br />