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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal =s2794 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Cadon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. MAI <br />W - 0 Lab. NoAs) <br />Sample Date W - ;- / - /5 Time 1 y . � � D <br />Collected By 2 0 4 <br />Field Custodian &6 / P n i G <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />l.viaCr <br />vu-a,.c vcawua.,vu <br />2 <br />t <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />40 <br />%- <br />i <br />Cs 5 o,2,-� <br />1. Sample Type: Air Water _,� Soil Other (specify): <br />2. Analysis — Test series requested: <br />3. Field Data — Preservation: % �L /�l • 1 e-2,1, L J - -e ' �— <br />/''�rr S- 6 3 u S �. `� . UT�"ti 10y act,•, t 46 .fir S 7 n,�: <br />zi Z4 <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 21 of 21 <br />