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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal Yn S 26355 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Cafion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. ? (1J - ?O/ Lab. No.(s) <br />Sample Date Time <br />Collected By <br />Field Custodian <br />Delivered B <br />Received B <br />Date Recd. <br />Time Recd. <br />a..v«Cr vu-ouc Lcauuuiiuu <br /> <br /> <br /> <br /> Ploy <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />1. Sample Type: Air Water f Soil Other (specify)): <br />2. Analysis - Test series requested: <br />0C. . -9 I <br />178 ,z -2- 7 a .?. 2 9 4 , . <br />3. Field Data -Preservation: <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 />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( } NO( ) If NO, explain: <br />QAC <br />) and explain below. <br />Date <br />Page 14 of 20