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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ;a.'2 25199 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. - Lab. No.(s) <br />Sample Date r3 - Time - r <br />Collected By ??-- d -? <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />. VtMl f <br />y'A,.L' f'Ar. I ;vu-oue Vestinauun <br />.may y.? t? •af" <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br /> <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: 77- /0 <br />/ <br />) a t.- ' <br />3. Field Data -Preservation: <br />,d r <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- Explanation of noted items: r ' r <br />e' <br />( ) Check if additional' attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC Date