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COTTER'CORgORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal St$7 t$ <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. it/_ ;j 2 Lab.No.(s) <br /> Sample Date 1: le- /I Time 1/ u J Date Data Entered <br /> Collected By /3, 2, / I rr G ri Data Entry By <br /> Field Custodian Vii fie'.-r ,.r d - r Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By e, : Q- . /! - 1 t _ '. -. I (;. . <br /> Received By , <br /> Date Recd. 1/r 7/16- <br /> Time Recd. 1 d,o t! <br /> •i <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis— Test series requested: 1C ,)4 2, <br /> 3. Field Data—Preservation: T.' q ? (1 , 1 2 6 r. t <br /> ' e (t /7 i). , ;1 y "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 16 of 19 <br />