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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal AL S217 <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O.Box 700 <br /> Canon City, CO 81215 Callon City,CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. I W '" 0 Lab. No.(s) <br /> Sample Date 3- y "2 0 / Time lU: CO Date Data Entered <br /> Collected By Ai, fehr14 of r Data Entry By <br /> Field Custodian /.S 4 ?P frf n Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination 7 4, 11,1 7 ti t <br /> Delivered By e t f,•. r 2 '3 13 SS Ii' a . <br /> • <br /> Received By p4EX en� (7.4c p rP , W Y• •�7(D/ <br /> Date Recd. //7/(6 <br /> r <br /> Time Recd. [ 1•• /Zrf <br /> 1. Sample Type: Air Water-.�J Soil Other (specify): <br /> l <br /> 2. Analysis- Test series requested: 4 4/e <br /> 3. Field Data-Preservation: f`L 9. 2-` 4 b'C./ rte..r� 8 515 d 561L. <br /> r r ." 3 .75 Zt.- k ) Tw/,2.S , u -. y 4 /r 0.735' 11 <br /> 0. 7 5 L F%/V/1403 2p , / /6 //14 /1/v o3 <br /> D. S An; c0,, 2. <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 0116 <br />