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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 7.116 b <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Cailon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. <br />/i k1- C <br />Lab. No.(s) <br />Sample Date .2 7 ' 3 T Time 1300 Date Data Entered <br />Collected By e-'-1 'r Data Entry By <br />Field Custodian 1 T , r ^5 Laboratory Destination if not Cotter: <br />Cotter Off -Site Destination �,T r �, X r. /, . I I f, <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water ? Soil Other (specify): <br />2. Analysis - Test series requested: c 2, <br />3. Field Data -Preservation: <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 <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO <br />QAC <br />) and explain below. <br />), If NO, explaid <br />- <br />Date <br />Page 15 of 17 <br />