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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 112 s 25264 <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. 92, 5 _ 00/ A Lab. No.(s) <br />Sample Date 9 - 6. 2 o/u Time f, <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />V« & <br />. "WaI c yesunation <br />C? <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />N-S <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: S S f?_[??,? y ;, f , <br />3. Field Data - Preservation: Lc -e 41A-4 C a <br />4. <br />5. <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: 6iy Q <br />/and explain below. <br />t',' "14 . .0V gar <br />ZA.. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />Date <br />Page 5 of 6