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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal -• S 111753 <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.IID No. Do /s/ Q % G 0.4 l7 <br />Sample Date // `.? V ' 5 Time <br />Collected By /LC.? , T » H c .+ <br />/ <br />Field Custodian "So <br />Delivered By <br />Received By <br />Date Recd. <br />1/ 7 <br />-t_ <br /><.V«Gl <br />vis -oast La/asinemon <br />/zvT <br />rr ! l, <br />locNO <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Z 4 1 P.i J .S r /it ` . F' C� <br />"fro.F+. 4/Y. Z6o/ <br />Time Recd. ..01 ' c <br />1. Sample Type: Air Water 3 Soil Other (specify): <br />2. Analysis - Test series requested: T 4 / e 2. <br />3. Field Data - Preservation: %*tJ1I % 3 g fi 7. 7 ' �^ ^ r � 3 u S4 ^ �- <br />/q a r". r J3.7S- SJ `c DTW /t o% .0014 le S-47 5 dr? ., <br />0. 2 �'L ,�4 //A/di 2,11 , /f 4'T/) '/, ' 3 2 < <br />C>. S -G U/A f?x SU ,, -z. S <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 18 of 20 <br />