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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 112 S 2 5 4 S 4 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. C W -A 0-0/ Lab. No.(s) <br />Sample Date ?0/ 0 Time O 3 S o Date Data Entered <br />Collected By L7 Tp???G Data Entry By <br />Field Custodian _ r,?...•? G Laboratory Destination if not Cotter: <br />01- V% <br />Delivered By <br />Received By <br />Date Recd. <br />e <br />Time Recd. .. N <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: .S ,c h X? j <br />ej <br />3. Field Data - Preservation: T j 5 } 3 <br />IV d:3 2 5 -,n y / <br />L oq Al.- e.7 <br />4. Date analysis required by (if not Holding Time): _ <br />5. 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 />C=1-,4IYAl l? <br />G I//y . I G e <br /> <br />) and explain below. <br />Date <br />Page 35 of 37