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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal S 2$7 0 7 <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O.Box 700 <br /> Canon City, CO 81215 Canon City,CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. /'f14) - / Lab.No.(s) <br /> Sample Date 3 - i/-20/6 Time ) ' 5-0 Date Data Entered <br /> •f <br /> Collected By c 4 7 '° 'T Q fl Data Entry By <br /> Field Custodian 4 7r.4 h Laboratory Destination if not Cotter: <br /> Cotter Off-Site DestinationE/i 4�f f Z . 4 v ` /``e' s r". L <br /> Delivered By 04 r h:, 2 31. 3 su �f � o * 4, 1/ f <br /> Received By f i'!I' ) Q �� (1 It n'', (ivy 1 (u/ <br /> Date Recd. j 6 <br /> Time Recd. 1114 } e' <br /> 1. Sample Type: Air Water .5 Soil Other(specify): <br /> 2. Analysis- Test series requested: fa 4 IQ <br /> 3. Field Data-Preservation: I uC 9S Z / <br /> . . 7-S u V j -[ .L <br /> p n s , ,. .3' SG�R s `t , Dr .i 1577 pu.•-rj'fk/` 0.YS/9)4.-N <br /> P1-1' 11- FA I( 1114 4 9- 0.ti• <br /> u f A 1/4dC i 7. 5 <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 15 of 16 <br />