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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal _ S <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O.Box 700 <br /> Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. /���; /� F �. �! Lab. No.(s) <br /> Sample Date / 'i ! Time ` Date Data Entered <br /> Collected By Data Entry By <br /> Field Custodian = ' •!f i Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By A" 7 ram.f 2 _i' ; �. ' ' .• /' �• <br /> Received By /� �f �'✓" t ti ..._ /=� i! Z %; <br /> Date Recd. <br /> Time Recd. / <br /> 1. Sample Type: Air Water ? Y Soil Other(specify): <br /> 2. Analysis— Test series requested: <br /> 3. Field Data —Preservation: T 173 --V 7• cl <br /> 4. Date analysis required by (if not Holding Time): <br /> S. Special handling conditions or other instructions: <br /> 6. Invalidating circumstances? If YES initial ( ) and explain below. <br /> COMMENTS—Explanation of noted items: <br /> J � \ <br /> 1 <br /> if additional attachments. <br /> QA Review: `` <br /> Sample valid? YES ( ) NO ( ) If NO, explain: <br /> QAC Date ( I <br /> Paae 7 of 7 <br />