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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ti? S 2 5 316 <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. _] (4-,l IS() rS Lab. No.(s) <br />Sample Date 2,04---) Time <br />Collected By (n r/ <br />?. <br />Field Custodian X. ?? .? e <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />I- a.r <br />a <br />4. „;:;e8iysisuired by (if not Holding Time): <br />Special handhinj4omd- ions or other instructions: <br />{ )and explain below. <br />IittmUdgktfag ?ircum?stances? If YES initial <br />s? ? ?.,?a?[b'tlob-af noted items: <br /> <br /> <br /> <br /> <br /> tonal attachments. <br /> <br />QA Review. <br /> <br />$; va ; 'ILLS ( ) NO( ) If NO, explain: <br /> <br /> <br />t? ??.14 <br />4- <br />? y QAC Date <br /> <br /> <br /> <br />j ?; -tom <br /> <br />•,vuer vu-?iw LCSNIIiILIU?i <br /> <br /> C" I <br />?. -a kcn - 1- 4u. <br /> C <br />&s A <br />- Test series requested: c <br />Page 13 of 20 <br />1. Sample Type: Air Water .__, - Soil Other (specify):