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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal s 25227 <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. /) r S 0O 1A Lab. No.(s) <br />Sample Date Time <br />Collected By <br />Field Custodian ?. . ?? <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /> a.vaam V11'W {c L6J Utl ii LlUll <br />G <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />1. Sample Type: Air Water C) (? Soil Other (specify): <br />2. Analysis - Test series requested: 7-6 ? / (' Z <br />3. Field Data - Preservation: <br />12 <br />14 <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: <br />( /' ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />Date <br />Page 22 of 22