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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal l v : s285 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. .Sg.i #4,1 p — <br />Sample Date /1 ' // ` / S Time / -� `-) <br />Collected By %3a 4 Tisk <br />Field Custodian t 6 ro .00 G r? <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Off S't De t' ti <br />4V14cr <br />- 1 e S m8 oa <br />T <br />Fel X <br />�Itc. <br />a <br />wizto <br />1a 15 <br />1. Sample Type: Air <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />�Htor�S. LL. CoreG- <br />Z 3 SG /r` C�i. o r if //ti y <br />s / 74-o( <br />Water —' Soil _ Other (specify): <br />2. Analysis — Test series requested: 7-4.z le 2-- <br />3. <br />3. Field Data — Preservation: T 't / Z • g /6, #o • �Vr ,- c/ i e'�d fL/, ,/ y Z. <br />"1NS P r'u,t-J y67 f., S i !- `C )) L✓/i S �'u -%r %iJ! J 7. �/—� f7 .1� <br />C0.2S L r 4 ,,/ .% 7 -Z 7 H , / (/ 7- // // 4./ c)1 2 ✓..,, C. - <br />r• ✓ <br />0. a / a /A ;'--' S,-, 7. 5 ...- i <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 ( <br />) and explain below. <br />COMMENTS — Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( <br />If NO, explain: <br />QAC <br />Date <br />Page 15 of 16 <br />