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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal %'qn S �T <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />N: P.O. Box 700 <br />Canon City, CO 81215 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. ,, 11 1. Lab. No.(s) <br />Sample Date <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Time ! <br />-��.�1 <br />v.,-auc �,esusazwa <br />DA <br />t <br />M. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />3 <br />L J <br />l a. <br />I. Sample Type: Air Water Soil Other (specify): <br />2. Analysis — Test series requested: % by, 2- <br />3. Field Data — Preservation: ' 0, �• 1 % 5 <br />4. <br />S. <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial <br />COMMENTS — Explanation of noted items: <br />) and explain below. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( } If NO, explain: <br />QAC <br />Date <br />Page 15 of 16 <br />