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L Y <br /> COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal <br /> C: P.O. Box 1750 S: P.O.Box 1750 <br /> Canon City, CO 81215 Canon City, CO 81215 N' P.O. Box Nucla, CO 81424 <br /> Sample Loc./ID No. C <br /> Lab. No.(s) <br /> Sample Date Time_ / _r ' s Date Data Entered <br /> Collected By , T �,�r t Data Entry By <br /> Field Custodian e' Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination F__ ,,. �•. �! { <br /> Delivered By <br /> Received By <br /> Date Recd. <br /> Time Recd. <br /> 1. Sample Type: Air Water ? Soil Other (specify): <br /> 2. Analysis— Test series requested: <br /> 3. Figg d Data —Preservation: t <br /> 4. Date analysis required by (if not Holding Time): 1 <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 15 of 16 <br />