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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 1v1 s25414 <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. f?x-S C9 0 Lab. No.(s) <br />A ?- 13 --- C.. <br />Sample Date 9"3a - Z °/O Time ?a n s ? r Date Data Entered <br />Collected By a .? , l1. _ Data Entry By <br />Field Custodian ; a ,71Ptnt?.oi, c -Z Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />VVL. L•Ol- Vll`g1LG ilG3LlUii llVL <br /> <br /> <br /> <br />C? 1ctZ. <br />_IV r <br />a <br />n <br />1. Sample Type: Air Water 3 Soil Other (specify): <br />2. Analysis - Test series requested: ?- <br />3. Field Data - Preservation: V <br />4. Date analysis required by (if not Bolding 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? <br />YES ( <br />QAC <br />) NO( ) If NO, explain: <br />Date <br />Page 5 of 6