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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 12 S 25270 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Cation City, CO 81215 Canon City, CO 81215 <br />Sample Loc./ID No. Id IJ 1-> Lab. No.(s) <br />Sample Date 10-0 -'U Time Date Data Entered <br />Collected By ) 7'-"V N e W Data Entry By <br />Field Custodian 9 '' .' "L '" , ' Laboratory Destination if not Cotter: <br />Delivered By ' <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water-7- Soil Other (specify): <br />2. Analysis - Test series requested: re- 4 /14 1 <br />9 ?g > ^- .- 3 S ?• ?_ ?? ' t o <br />3. Field Data -Preservation: <br />It 0 <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: <br />( >< ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC Date <br />N: P.O. Box 700 <br />Nucla, CO 81424