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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ''1 <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. _ P/5 - o o /A Lab. No.(s) <br />Sample Date Time f;, ,?, Date Data Entered <br />Collected By Data Entry By r <br />Field Custodian )? 7r?„ ?l • ,ter Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.vaaca <br />J -r Vll•JAC LCa a1LL311100 <br /> <br /> <br /> <br />i <br />1. Sample Type: Air Water c; Soil Other (specify): <br />2. Analysis - Test series requested: ?, ? /< 3 <br />3. <br />4. <br />5. <br />Field Data - Preservation: <br />;z ;X r.) lVd <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br /> <br />6. Invalidating circumstances? If YES initial { ) and explain below. <br />COMMENTS - Explanation of noted items: <br />( X ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC <br />Date <br /> <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Page 22 of 22