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COTTER CORPORATION SAMPLE S }UBMITTAL AND TRACKING FORM <br />Sample Submittal 27820 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. Lab. No.(s) <br />Sample Date -2 Time <br />l T <br />Collected By ` <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water <br />2. Analysis — Test series requested: r <br />3. Field Data — Preservation: ' <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />l <br />oe <br />Soil Other (specify): <br />J ; <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 />) and explain below. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC Date <br />Page 23 of 23 <br />