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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal s2 5362 <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. -19 6?/ / ?3 If?i--- Lab. No.(s) <br />Sample Date Time 14 1.' 7. 0 <br />Collected By ?- <br />Field Custodian `. r'!' .? ... e' <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /> <br /> <br /> <br /> ?e <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />1. Sample Type: ' Air Water / Soil Other (specify): <br />2. Analysis - Test series requested: rc <br />3. Field Data - Preservation: <br />J, ?2 t r <br />-14 <br />/ C?, 4 i- ,? // a ! 2 5 <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: >A <br />( A ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( } NO( ) If NO, explain: <br />QAC <br />Date <br />?IGG ?(?5- 3 8 <br />Page 31 of 31