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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 11,") s 26351 <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. S o,- / A Lab. No.(s) <br />Sample Date /0 1 u/ Time - , Date Data Entered <br />Collected By Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Delivered By <br />Receive <br />Date R cd. <br />Time Recd. <br />•.va?ca vu•unc Lcauua?wu <br /> <br /> <br />$ l/ ld <br />9.'4D <br />?r <br />c <br />dw <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: u??=)n? r?•?- ?? r4 f <br />o? <br />3. Field Data -Preservation: r /• `? .? Ar/ <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 />Page 8 of 8