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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ? .1 S Z 1 77 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Canon City, CO 81215 Caiion City, CO 81215 <br />Sample Loc./ID No. -9 CrJ ,4 w IJ Lab. No.(s) _ <br />Sample Date 2 ("?? -/ 7cyonme ? y0 <br />Collected By !3 <br />Field Custodian??? c -•.'`? <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />\.VL?cl vu'ouC LCSLl117tl?VO <br /> <br /> <br /> <br /> <br />1. Sample Type: Air Water _ <br />2. Analysis - Test series requested: <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />0." <br />Soil _ <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Other (specify): <br />3. Field Data - Preservation: T /L/, ill <br />S: 0 7 s ?, z, l -L f 4 Hit/ <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: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />Date <br />Page 37 of 44