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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal :112 S Z 5 3 6 0 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. .., W " L L Ale'- <br />Lab. No.(s) <br />Sample Date 20 J Time 0-10 <br />Collected By tZ r~r ?N <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />VVLLCl V1l?JlLC LCDLWAUVL <br /> <br /> <br /> PEP <br />904 <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br /> <br /> <br /> <br />i rr . <br />' - N ? <br />• C <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: T. 1. <br />3. Field Data - Pteservaation: 0 u/s 1 <br />/'i •.v f r" fi'r` • d • ?, d 5 i.f.,? <' ,r i ' ? fJ ? L ? s?? ? ?'?!.'% ?, ? ,1_... ,. ?' ? I G? <br />lVe <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: .CC / ?: h /e 1 <br />( )k/ ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />'b <br />QAC <br />Date <br /> <br />CIjQOgos'3,? <br />Page_29 of 31