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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ?? S Z5223 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 CaOon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No.- a .e_ Lab. No-(s) <br />Sample Date 7-7 4) Time <br />Collected By j-? <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />,? L,.VLLCC VlYO1LG 1lCDLll?aullvu <br />-mar= <br /> - <br /> <br />qy5 Inc) 20* lQ <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: T?- 1, Ae 3 2 ^^ ? N y L.A/ <br />3. Field Data - Preservation: 71 <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: <br />/:. ).. <br />fe 1, <br />( / ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC Date <br />Page 24 of 25 <br />) and explain below.