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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal sZ$755 <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. tC Lab. No.(s) <br />Sample Date II <br />Collected By !.. , .< <br />Field Custodian <br />f3.A0 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />I..ULLLR <br />J1I'01 LC L/IMMOLLVLL <br />.- <br />• <br />fi <br />:s• <br />V 7 5// <br />10;K0 <br />1. Sample Type: Air Water <br />2. Analysis — Test series requested: <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Soil <br />7 <br />Other (specify): <br />3. Field Data — Preservation: 1 f <br />/ / f <br />1 /. Q ;'"‘7,1", <br />7/7 <br />./ e <br />,. 2,20 . <br />01,2- <br />t, <br />,2 - <br />E f' A , <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 17 of 20 <br />