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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal . m2 S25187 <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 r %'% I Lab. No.(s) <br />Sample Date' ' r Time e' <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />?••«?l v?i-aite Destination <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />a r¢ <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: f ..? , <br />.s <br />3. Field Data - Preservationa <br />p f.. <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 ( ) and explain below. <br />COMMENTS - Explanation of noted items: ? ' <br />?- 1 C? 3 <br />( k ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( <br />) If NO, explain: <br />QAC Date