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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal N' s241,27 <br />i <br />C: P.O. Box 1730 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Caflon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. , ' "yo l q Lab. No.(s) ! <br />Sample Date t - `�' / S Time <br />Collected By <br />Field Custodian i? 4 T 'y7 n G .1 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />%Iww c <br />v11-0199 uoeuasuva <br />1 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />f"� �CAq <br />2 ...? ! 3 JC fly 1r /P�lfGJS/. <br />('9e r,, A/ 27 Xv/ <br />1. Sample Type: Air Water 4r Soil Other (specify): <br />2. Analysis - Test series requested: LG <br />h <br />3. <br />4. <br />5. <br />Field Data - Preservation: C � .q �► l F6 . ,' F17 - <br />0• 2- z. 4e '—.4 ilAl0 <br />/I a _� 0 2.r, - <br />Date analysis required by (if not Holding Time): <br />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 Re *.iew: <br />I <br />gample valid? YES ( ) NO( <br />QAC <br />r <br />) If NO, explain: <br />Date -- <br />Page 19 of 19 <br />