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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S 2 53 8 t <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 E V Canon City, CO 81215 Nucia, CO 81424 <br />Sample Loc./ID No.. _ 4? 6(11 Z7) I- ?- Lab, No.(s) <br />Sample Date l0 CYOhme /4 !V <br />Collected By O N <br />Field Custodian 4? TG' ., ti r <br />Delivered B? <br />Received By <br />Date Recd. <br />Time Recd. <br />??+«c¦ <br />?..•r.wr- ?. % ULA-alLC VC391natioll <br />i o. L c , <br />td, <br /> <br /> <br /> <br />1. Sample Type: Air Wate <br />2. Analysis - Test series requested: <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />r <br />_'f? <br />Soil Other (specify): <br />/ <br />3. Field Data - Preservation: 6,7 9 4' 1.? <br />r <br />41 U S ". s <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES i al (/ ) 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 <br />Date <br />Page 30 of 37