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• <br /> COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal " •" S 217 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. yf Lab.No.(s) <br /> Sample Date 3- - 1)`�. Time 13 : `' Date Data Entered <br /> Collected By 1 L -, ' ".'7./ l{ ' Data Entry By <br /> Field Custodian )1, ' . .+ :+ r _+ Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination •1 i I f <br /> Delivered By •P ` ' T r'. 1+ 2 _71 < C r /i' r r <br /> Received Byr <br /> Date Recd. 1/111/6 <br /> Time Recd. (1:041f <br /> ( <br /> 47:--• <br /> 1. Sample Tpe: Air Water Soil Other (specify): <br /> 2. Analysis- Test series requested: 7. ' I,. 7 <br /> 3. Field Data-Preservation: / t` / 0• p s/ 7. 91' '°.,..��,"�►/�.� + f `f <br /> `-I)? ,j ' • t - ice/ r 17 ) 1)T 37/. s-3 r r"`x <br /> 6 1 c L / .1,./4/6‘.1 ,r' , /f . - ,'1' 3 .2 t, <br /> s /. /1' ,, , S4. �? ... ;. <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 18 of 19 <br />