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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal • " S 2 5 418 <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. SW A 00 / <br />Sample Date /d " 7 e!) Time 10 0 SA <br />Collected By ?3 r h?n: iv -? -' <br />Field Custodian '4 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.v«ca <br />I? 7 <br />?/V tom/ V' ? Vll'?711G LCJlIIIiltlUII <br /> <br />? iJ 1. t- <br /> <br /> <br /> f <br />1. Sample Type: Air Water / Soil Other (specify): <br />2. Analysis - Test series requested: ?:2 :'P' c <br />3. ]Field Data - Preservation: 7.1 ? `f <br /> <br />4. <br />5. <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <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 <br />) If NO, explain: <br />QAC Date