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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />'2 <br />Sample Submittal 1#,?_ s26248 <br />, <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. S 4l A tc-1 Lab. No.(s) <br />Sample Date j nr-,26-2 0/0 Time + <br />Collected By J-Z' /?..?. <br />Field Custodian /y /too-., <br />i <br />Delivered By <br />Date Data Entered <br />Data Entry By <br />Laboratory Destijation if not Cotter: <br />Received By <br />Date Recd. <br />Time Recd. o? <br />GIN <br />1. Sample Type: Air Water ?r Soil Other (specify): <br />2. Analysis - Test series requested: (2"(Ae I <br />3. Field Data - Preservation: 7' y? y ?? / 7 39 ('2'7 ,A,p/ 3 S 5 _u S &'A s <br />4. <br />S. <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 />) and explain below. <br />{ ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES { ) NO ( ) If NO, explain: <br />QAC <br />Date <br />,Pans 29 of ?2