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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal S Z 1 9 5 5 <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 CaOon City, CO 81215 Nucla, CO 81424 <br /> Sample LocJID No. (•/ 14 ' )7 Lab. No.(s) <br /> Sample Date -1 LIK Time O Date Data Entered <br /> Collected By T Data Entry By <br /> Field Custodian j F`•�y, �• , I`- <br /> Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By � <br /> Y . <br /> Received By / f r c <br /> Date Recd. <br /> Time Recd. {{'•15 <br /> 1. Sample Type: Air Water S^ Soil Other (specify): <br /> 2. Analysis— Test'series requested: <br /> 3. Field Data —Preservation: f `It { "' �. <br /> _ 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 t ) If NO, explain: <br /> QAC Date <br />