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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal L.: S •: <br />P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Cayion City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. � C �C ' f • { <br />Sample Date J }_Time p J <br />CtIiected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />3. <br />#r <br />4 4. <br />A. <br />VV11Ci <br />V111011C 116611UWUVU <br />1 <br />/! " <br />r <br />�0 3 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />}•� •' .l c <br />r ✓ P oe <br />Sample Type: Air Water _ ' L Soil Other (specify): <br />Analysis - Test series requested: <br />Field Data - Preservation: L of 7 ;L > 7 a <br />�f. ?. � L / "J i /�+r� rJ � 2 r,% 4j/`_h <br />Date analysis required by (if not Holding Time): <br />S. Special handling conditions or other instructions: <br />6. Invblidati'iag circumstances? If YES initial <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( <br />r <br />) and explain below. <br />) If NO, explain: <br />QAC Date <br />