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COTTERCORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal #' 21114 4 <br />C: P.O. Box 1750 S• <br />P.O. Boz 1750 00 <br />7 <br />Box P.O.x <br />N: Canon City, CO 81215 Callon City, CO 81215 P.O.NucB x 7 81424 <br />Sample Loc./ID No.Mw 13 Lab. No.(s) <br />Sample Date Time g J <br />Collected By C <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />u••//�K• <br />vii -sue ureusa«va <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Jr,f G•� � �'w� <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis — Test series requested: <br />3. Field Data — Preservation: t iF • 7 r., c c_ <br />oJ <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( ) If NO, explain: .. <br />Vic Date <br />Page 14 of 15 <br />