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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal „.e S i <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Canon City, CO 81215 Canon City, CO 81215 <br />Sample Loc./ID No. 13, ? 0 //4 - _' Lab. No.(s) _ <br />Sample Date ? Time ' r< ' -.. c+ <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />?.??wi ,eVll'JIIC LCJNllQllVll <br /> <br /> <br /> <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br /> <br /> <br /> <br /> 3 <br /> ?y <br />s rr <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: ! } ,? 5 - 1 ,--- 4 Z< <br />3. Field Data - Preser"tion: <br /> <br /> <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: e? 14 r` ,/ f-"- <br />) ( Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC Date