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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />C: P.O. Box 1750 5: 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. q W ?l3/' L Lab. No.(s) <br />Sample Date Ste--! ?O-ftme _ /D ::K S <br />Collected By .CS / p.?ra, a .? <br />Field Custodian.. <br />!Y . <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />. UWWWa <br />r Vwafitc UCsunauoa <br />? 41 - L <br /> -70 <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination H not Cotter: <br />a <br />.A0 <br />a <br />1. Sample Type: Air Water -?L Soil Other (specify): <br />2. Analysis - Test series requested: G <br />3. Field Data - <br />4. <br />5. <br />6. Invalidating circumstances? If YES initial ( ) and explain below. <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />Q.al Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC <br />Date <br />Page 28 of 29 <br />Date analysis required by (if not Holding Time): <br />Special handling conditions or other instructions: