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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM' <br /> Stemple Submittal S 4 <br /> C: P.O. Box 1750 S: P.O.Box 1750 <br /> Canon City, CO 81215 8 N: P.O. Box <br /> Canon City, CO 81215 Nacla, CO 1424 <br /> Sample Loc./ID No. S ty 9 Lab. No.(s) <br /> Sample Date Time ,� . "i Date Data Entered <br /> Collected By "`� ` T r .�r!f Data Entry By <br /> Field Custodian i �' 1 r i7 e"j Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By <br /> Received By <br /> Date Reed. <br /> Time Reed. <br /> I. Sample Type: Air Water Soil Other(specify): <br /> 2. Analysis— Test series requested: <br /> 3. Field Data —Preservation: % A _/ , <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 />