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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittals S <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. _? (41 13 /a/... Lab. No.(s) <br />Sample Date Time `- Date Data Entered <br />Collected By - -? •-? ?' - Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /> a..V?icr vaa?-t/oliac aic?uua?wu <br /> <br /> <br /> 3 ? <br /> <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: N / r._. ( • S .:.? <br />7 17. ti ' 7, S6 38? ," "XI <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 Date <br />) and explain below. <br />Page 20 of 20