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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal . "' 5 2 5 4 5 2 <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 ("/ - A W I-) Lab. No.(s) <br />Sample Date ? '17` 2 eVO Time /3-22 <br />Collected By L? I 0 ?- C "-µ <br />Field Custodian J? % /y <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /><. V?LGl Vll'J1lC UCJ l1Lil LlVll <br /> <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />(11 1. Sample Type: Air Water 7 Soil Other (specify): <br />2. Analysis - Test series requested: S Tc. 1,e 1 <br />3. Field Data -Preservation: <br />3. I' A 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 />( Y ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC Date <br />Page 25 of 25