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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i'. S 28357 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. 5&) A (J D Lab. No.(s) <br />Sample Date 7' 2 / 5 Time <br />Collected By /J<. 7.4'.1 n c <br />Date Data Entered <br />Data Entry By <br />Field Custodian /L. � 7.'r .Fin cry 7' Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />T' Recd. <br />Time ec . <br />1. Sample Type: Air Water C. Soil Other (specify): <br />2. Analysis — Test series requested: 7 4; / e / <br />3. Field Data — Preservation: ( t ) g . y i y 7, /3 '' �, 3 / 7 k <br />3./2u S , `( / t'w % /i A/0.s 2 c) � S ), ) <br />17- ; c 1 z , _ t./fl /.ltdO, Z G ///c, G . S L. OI/ / .. -6f <br />2.5 / 0. 5 L G/F7/ Al„ 0 // Z. <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />Off S't D t' ti <br />.UIICL <br />Ie esma on <br />°1131!5 <br />1�=35 <br />7Z i7 S /r (1/- ,¢ <br />r e , IV/ Y. :' Z t I l <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 />aVC <br />