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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal _ ::"S25317 <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. l /61- Lab. No.(s) <br />Sample Date -? 2,),,,,-) Time 1 <br />Collected By .7 <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water Soil Other (specify): <br />n#ysis - Test series requested: S re <br />fy #: <br />04 <br />3 .A. Preservation: Z ccL c • ?c <br /> <br />4. Date analt'y ire"d,by (if not Holding Time): _ <br />?".r handg conditions or other instructions: <br /> <br />es? If YES initial <br />noted items: <br />) and explain below. <br />.1. h, <br />y v <br />alattachments. <br />Oeevrkl?..'?` - <br />$aimple val Y' <br />) NO ( ) If NO, explain: <br />QAC Date <br />,x <br />yam; <br />s' <br />h <br />1 f?f .fife, Ti'°•.j??jAN <br />rte. ..: .L?. .nc <br />.i?piiCio.'?s2rt.`ti ?. .. ? :rrriii'Gr.!i•: ':++?t.at.wwaw-:« <br />liV ilcl Vll'?7UG LC511?14 ?1UII <br /> l? / II <br /> <br />.5. $- ?CSZ ynQ,1?1 <br />`(1/J?1 <br />1JISr <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />6a%-. <br />Page 14 of 20