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1 1 P <br />1111...1111111111101 <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal �`, y S 2$4 4$ <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. Mi n t A r'-' <br />Sample Date /.." ' / Time Q • 5 <br />Collected By ! ?n r, / <br />Field Custodian ! • F, ! -n effi (• <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />l-.uucl <br />vu.Ouc 1/VDNlfaLrou <br />t <br />. • <br />1( <br />(5(f 5 <br />i0;OZ, <br />1. Sample Type: Air <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Water / Soil <br />2. Analysis — Test series requested: T • '' 1, y <br />y • <br />C <br />/. <br />Other (specify): <br />3. Field Data — Preservation: ' L / v 0 <br />sy'l) - 1, ,, / It ') I <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 />