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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal _ 1"12 S27M <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. Of -e IC v A */ Lab. No.(s) <br />Sample Date S 1 S Time !2. y 5� <br />Collected By a i+ r <br />Field Custodian g",1. yi®rr W H <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />If ✓ S y 10 <br />X? 6 0 <br />'Mt✓S <br />1. Sample Type: Air Water tIr Soil Other (specify): <br />2. Analysis - Test series requested: & 4 ) r y <br />3. Field Data - Preservation: ;r* L d 100 S . 5 w► t `L <br />Ole /' rive, + 2J, (j yob 7 01& -4c !R 0 ..,., <br />2 >t ` L 4 F A s/_ -varlo <br />n. 7 3" L f A /ibis/ 2 all <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 U additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC Date <br />Page 11 of 13 <br />