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t <br /> COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal : S 2 1 P 55 <br /> C: P.O.Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> CaOon City, CO 81215 ' Callon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./IR'N4 i+=Tt f �l �'P►'��+���t�° �.t 1ES i N6:(h) <br /> Sample Date 14 f/L(Z /6 _Time IS—:SO Date Data Entered <br /> Collelstedyeti <br /> a- I t 1l�.Z'tl <br /> Field Custodian /3 '� /; ,1,f .� Laboratory Destination if not Cotter: <br /> -,,,,,,l,lt J AA ,I I o. Cotter Off-Site Destination <br /> Delivered By .�r��- f f; r i <br /> Reggaved:Ay �' �.. ;,: :t _ i S.,�1 c✓ � l d <br /> Ant@ ROdi) <br /> !T-AgW ftpd►t i s y <br /> I. Sample ape:- fir Wa1ei Soil Other (specify): <br /> 2. AnaIysis— Test series requested: / <br /> 3. Field Data <br /> —Preservation: <br /> / j/ � /9• D �� 7'!5'/ (" �„ , � f j L <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 /> n..•.^,O-4 40 <br />