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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal - _ s 2 720 <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._ /I kI-/ Lab. No.(s) <br /> Sample Date 7 /j 1t 'lime 1 iZ `T'S Date Data Entered <br /> Collected By 1. �fry , Data Entry By <br /> Field Custodian , .�n i I Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination r: , ,, L I f „ .� <br /> Delivered By ' 7 / <br /> If . . <br /> Received By + i f , f4`ti. ' 1, • Y <br /> Date Recd. 1/17/14 <br /> Time Recd. tR'0q <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis— Test series requested: r- <br /> 3. <br /> - <br /> 3. Field Data—Preservation: r -; $.4 /4/7' 7, /g 37 ,_ ' <br /> - 111'A ' // • � t ?', <br /> ,, <br /> f.' 9z w+ 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 17 of 19 <br />