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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal S 29 9S <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Callon City, CO 81215 Nacla, CO 81424 <br /> Sample Loc./ID No. 'en %' � Lab. No.(s) <br /> Sample Date // A !'- /f Time `7"5-p Date Data Entered <br /> Collected By J` % f .y:►, Data Entry By <br /> Field Custodian r < f'r;4- Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination / - <br /> ! s <br /> Delivered By �r''r 4q - r <br /> Received By <br /> Date Recd. <br /> Time Recd. <br /> 1. Sample Type: Air Water 3 Soil Other (specify): <br /> 2. Analysis— Test series requested: <br /> 3. Field Data—Preservation: <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 s Date <br /> Pano 1S of 1R <br />