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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 1; s2$472 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample Loc./ID No. Sa goe <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Lab. No.(s) <br />Sample Date /t>> " 7- /5- Time 7: ¥ 5 - <br />Date Data Entered <br />Data Entry By <br />Field Custodian '- / r' .v yr c n Laboratory Destination if not Cotter: <br />Collected By gi T Prtn 4 t <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />l.v11.Icr <br />IJL1`01M 1JCAL1LLa NVUL <br />130‘ r <br />- <br />/Er <br />NV <br />�.ts <br />lto•ZD <br />1. Sample Type: Air <br />23c 3 EA if C/r <br />(3,, 5r« , w y h2 dI <br />„ ri <br />Water S Soil Other (specify): <br />2. Analysis — Test series requested: To ! •' / <br />3. Field Data — Preservation: % ` ( I 1 • 3 ✓_ 4 7 `/O (, , ! Y 39 c.• f z , r <br />r / A " r• -,7 2. /.? c. .i,.,Ic i `c 0.2 : G fir ///1/1 -I/2 71 <br />/6 (i/4h1/r/di 2 U..,., (', o, z 5 Lu/ l 0, Z-z!r"/4//2 SL•Y 2 5;... ( <br />0. S e a f /? Ne O t-/ 2) f <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 />Pana 17 of 1R <br />