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Ci cllai <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal s2$522 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample Loc./ID No. <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 Nucla, CO 81424 <br />Sample Date <br />Lab. No.(s) <br />Time /1 • ) Date Data Entered <br />Collected By ; <br />Data Entry By <br />a <br />Field Custodian Laboratory Destination if not Cotter: <br />, <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />*6...1./ILVI <br />W11.011C L/C51.11.1131.11/11 <br />i <br />i <br />i - <br />fid <br />1 <br />, <br />i•• <br />I. <br />I.. • <br />e • • <br />- ( <br />I ' \ <br />r \ <br />1 '..• <br />• <br />1. Sample Type: Air <br />(.- I <br />Water •' Soil <br />2. Analysis - Test series requested: /.- V <br />2 3 7' ".1.- <br />Other (specify): <br />3. Field Data - Preservation: - •/ '0 <br />C ) g 5 <br />A • <br />/i .0"1, -1; rt: C <br />9r/ <br />• <br />1 <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 8 of 8 <br />