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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal :L' S 2 5 4 8 4 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. -_ C /'&/ 13 IL- Lab. No.(s) <br />Sample Date "i' S 1 0' ' Time 102 y 0 Date Data Entered <br />Collected By r - Data Entry By <br />Field Custodian v Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />VVLLGI- VLL'+71?c LG.?una?+vu <br /> <br /> <br /> <br /> <br />1. Sample Type: Air Water j Soil Other (specify): <br />2. Analysis - Test series requested: <br />3. Field Data -Preservation: / t' • ? -2 ?• ?.5 ?; 1 l 2 S r j 17 <br />4. _D#W analysis required by (if not Holding Time): _ <br />5. Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial <br />COMMENTS - Explanation of noted items.: <br />) and explain below. <br />,.:. <br />( ) Check if additional attachments. <br />"A Review:" rr?? <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />Date <br />Page 44 of 44 _