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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal c '' 5 2 5 3 2 0 <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. C (-.? (j S Lab. No.(s) <br />Sample Date ?,2 -2 d " Time 15 f Date Data Entered <br />Collected By ')s Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Other (specify): <br />I.VLLCC V?a-oiac •rcauuawvn <br /> <br />J.-S ID b <br />V315 <br />G? <br />1. Sample Type: Air Water Soil <br />2. Analysis - Test series requested: ?' "'r <br />h <br />C' r <br />n t- <br />3. Field Data - Preservation: T I ?? <br />/.3 <br />4. <br />5. <br /> <br /> <br />d-C <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />b. Invalidating circumstances? If YES initial <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br /> <br />) and explain below. <br />Date <br />Page 17 of 20