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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S 25272 <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. -5611-113 D L s Lab. No.(s) <br />Sample Date / o, - / I " 2.-,'l ) Time Date Data Entered <br />Collected By )? Data Entry By <br />Field Custodian J=> Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />4? <br />?.UL?Ci- <br />.?.- viraiac ucauuwssvu <br />"Ov <br /> <br /> <br /> <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: <br />3. Field Data - Preservation: ?c o?a <br />73 <br />l 0, <br />4. <br />5. <br />4 <br /> <br />r-9 .r7 <br />2, ? J <br />-t. % - .- <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 />) and explain below. <br />QAC Date