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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM C+ 1 5 1 10(4(02._ <br />Sample Submittal s28524 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample Loc./ID No. (4 141 C) 0 <br />S: RO. Box 1750 N: P.O. Box 700 <br />Cafion City, CO 81215 Nucla, CO 81424 <br />Sample Date // -1 7 - S Time /'?' c3 <br />Collected By I3.,4 <br />Field Custodian la 1P .. nr <br />Delivered By <br />Received By <br />Date Recd. <br />TIme Recd. <br />4Vbb01 <br />Off -Site uestmanon <br />.. / <br />i <br />Fx- <br />f,,c/f--- <br />• ... <br />• -. <br />Qt,w <br />Li 05 <br />- <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />epProly Le•6o-a %vir �c x�r✓ <br />2 3 5' 3 S tt - e e k /1 .. <br />,re• L✓/ S,2 CO/ <br />1. Sample Type: Air Waters _ 7 V Soil Other (specify): <br />2. Analysis - Test series requested: / G' b ft 2- <br />3. <br />3. Field Data - Preservation: % 'L /. 7 or2/// 7. /5- ('..j. 3 71 <br />rens e ,... I.1Y3 �, Su�z S' o� l)iw 5 -Si, u �.-€..1Q 0.5'1 r,.�.. <br />0.2 N- L FAWNO1 2/9H /G /fiy //4/d3 2 a _/1 <br />o,s! L.erF/i N2 SVy <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 16 of 17 <br />