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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal _ i .' s 25319 <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. _57 w-/3 d S Lab. No.(s) <br />Sample Date 0711me y Z S° <br />Collected By <br />Field Custodian ! T?.- G <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.v?icr vu-ouc ucsuura?ivu <br /> <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br /> <br />1. Sample Type: Air Water. ( Soil Other (specify): <br />2. Analysis - Test series requested: ? j G ? f 4 <br /><.. <br />0- cv, <br />3. Field Data -Preservation: T 'a . 7. 3 r' e,? t A S ' <br />:.q <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 />?? c,*? Page 16 of 20