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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ? W'_ S25460 <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. D t c - 00 /A Lab. No.(s) <br />Sample Date 1 u l• % Time Date Data Entered <br />Collected By -ZP ti e, ?t Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />I.ULLCC Vll•JILG 11 GJ ?JUOS?vu <br /> <br />d• <br /> <br /> <br />r <br />1. Sample Type: Air Water / Soil Other (specify): <br />2. Analysis - Test series requested: -f re- 1 Le 3 .11' r, / ` <br />3. Field Data - Preserv <br />r- <br />4. <br />5. <br />r., t <br />7,2 6 <br />Z. i,1F14 N 17 ON <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial <br />COMMENTS - Explanation of noted items: > <br />( x ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />and explai?7n below. <br />l F <br />J :_A ( r: i..{ <br />Date <br />1U DpSb7cP3