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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal `' <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Ca3ou City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. /1 W - Lab. No.(s) <br />Sample Date l < 7 1 `: Time 11/ / u' <br />Collected By <br />Field Custodian / Z • <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />.•«�■ <br />Vil•OILC vcauLnLion <br />t c'AM <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />1. Sample Type: Air Water ? Soil Other (specify): <br />2. Analysis — Test series requested: e 1 <br />3. Field Data — Preservation: <br />I �7W <br />x <br />4. Date analysis required by (if not Holding Time): _ <br />5. Special handling conditions or other instructions: <br />b. Invalidating circumstances? If YES i$itial (• <br />COMMENTS — Explanation of noted items: <br />and explain below. <br />I <br />r <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO t ) If NO, explain: <br />QAC <br />Date <br />Page 16 of 17 <br />