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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal :11" s25415 <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 LocAD No. D; s (;7o /A Lab. No.(s) <br />Sample Date l 0 ' - 2 n/ Time 1 to Date Data Entered _ <br />Collected By <br />?P•+--.•? Data Entry By <br />Field Custodians "I,," Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.vaaw v11-01LC "CUInnLlun <br /> <br />l • `af •rb 1?1° <br /> _?_ <br /> <br /> <br /> <br /> <br /> <br />?r <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: T?? ?c z <br />o? <br />3. Field Data - Preservation: Uv 0;1, -IZ g cz <br />4 <br />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 />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( } If NO, explain: <br />QAC Date <br />Page 22 of 22