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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal t S 1154 <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. m W - a U Lab. No.(s) <br />- <br />/ `/ ' / ) Time <br />O o <br />Sample Date /- <br />Collected By _ J -S i S I P.1 "C .� <br />Field Custodian Zt, 4. Tem <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />%..VttC■ <br />vu -01W yceamnuuu <br />or-,. 64e <br />T h1 <br />S� <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />r <br />r r3 * n rJ <br />C `~ <br />1. Sample Type: Air Water 3 Soil Other (specify): <br />2. Analysis — Test series requested: LA 4 /< --I- <br />3. Field Data - Preservatlon: r c C v `% 6,9 6 - . G 6 G w u/' <br />r -I r P r< �- (:,/ 2. 1Y 16- FW // flus r <br />nTw 5 3 <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 />QAC Date <br />Page 29 of 30 <br />