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COTTER CORPORATION SAMPLE SU9MITTAL AND TRACKING FORM <br />Sample Submittal <br />C: P.O. Box 1750 . i <br />S: P.O. Box 1750 N: P .O. Boa 700 <br />Callon City, CO 81215 Caiiou City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. r O 01A -?. <br />Lab. No.(s) ;` _, {.....; ' .. s ?. • ?-:. <br />Sample Date o - 9-2. o//a, Time ('r) -- oU t it Date Data Entered <br />Collected By /. Data Entry By*?# <br />Field Custodian ?- <br />??pratory$catiuaHon if?l?t'Co?ter: <br />Cotter Off Site Destination <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /> <br /> <br /> <br /> <br /> <br /> <br />1. Sample Type: Air Water r~ ?? <br />? Soil ' Other (specify): , <br />2. Analysis - Test series requested: ? C4 <br />t.. <br />T ? ? ?:? ?t Od' b*3 y2 5 <br />3. Field Data -Preservation: 7 2 ? <br />, OM ?ft i s ,- <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 <br />'1) <br />COMMENTS - Explanation of noted items: , ? 1t j <br />and explain below. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC Date <br />?age8of8,