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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal - S2a755 <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. /'' u - 0 Lab. No.(s) <br />Sample Date // -2 y' / 5 Time i 3 . A 0 Date Data Entered <br />Data Entry By <br />Collected By <br />Field Custodian ?nick. t <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />I. Sample Type: Air <br />Laboratory Destination if not Cotter: <br />2&IS S.(rCrrr•k /71u7. <br />eas"n�, wY,f260 <br />Water Soil Other (specify): <br />2. Analysis - Test series requested: ra L !c <br />3. Field Data - Preservation: 1° G / /• g N6,Qy/ir l'n,-- J7/9 90ti `L <br />e t^. 2.70 IA . ( 17 r w / Laj, 0. %X ee,..,. <br />0.1- S L.. FA // #it, ci l /) I‘ tel A H Ai () 10 <br />a O. S lr NfA // SOS . <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 20 <br />. V LICL <br />lllI IIC LC 1411111.1011 <br />v <br />sk, / <br />ft% _ <br />.. <br />� <br />11/21A, <br />IC 14 11 <br />I. Sample Type: Air <br />Laboratory Destination if not Cotter: <br />2&IS S.(rCrrr•k /71u7. <br />eas"n�, wY,f260 <br />Water Soil Other (specify): <br />2. Analysis - Test series requested: ra L !c <br />3. Field Data - Preservation: 1° G / /• g N6,Qy/ir l'n,-- J7/9 90ti `L <br />e t^. 2.70 IA . ( 17 r w / Laj, 0. %X ee,..,. <br />0.1- S L.. FA // #it, ci l /) I‘ tel A H Ai () 10 <br />a O. S lr NfA // SOS . <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 20 <br />