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d <br />r <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal } $ s 9, 7 <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. Lab. No.(s) <br />Sample Date Time Date Data Entered <br />Collected By Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Cotter Off-Site Destination <br />Delivered By -= <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: <br />3. Field Data - Preservation: <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 - Explanatiain of noted items: <br />( , . ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( <br />) If NO, explain: <br />QAC Date