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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 1' §25464 <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. 17 S ° o o 1A Lab. No.(s) _ <br />Sample Date _?y" p/c? Time ! •+? ?? ' , <br />Collected By Field Custodian Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />VVt?ea' vaarouc Lc?uua uvu <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />P <br />Q N <br />1. Sample Type: Air Water u Soil Other (specify): <br />2. Analysis - Test series requested: 7r Jt ? <br />3. Field Data - Preservation: ' 17 .2 Y S' { •v ?? / y %? `• ; ??r s <br />r ,r <br />l (r J`/? /'f 4/v-7 <br />/- C1 S U i iii'. O f1 2'' y <br />4, Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />ti. 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 />N: P.O. Box 700 <br />Nucla, CO 81424 <br />r-t-• Page 22 of 22 -