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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S 2S S 1 t <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. 1? r S 0 Lab. No.(s) <br />Sample Date f 1 ?y' 1 0! ' Time ^^ :.p s Date Data Entered <br />Collected By % 1 ?P.?.? Data Entry By <br />Field Custodian 1 T' v Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />T'me Recd <br />[ osier v..-o..? ...?....... . <br /> <br /> c?- <br /> <br /> <br />i <br />1. Sample Type: Air Water <br />2. Analysis - Test series requested: <br />0 4 -? ? ? ! ? v rte, ..7 Y V <br />3. Field Data - Preservation: <br />4. Date analysis required by (if not Holding Time): . <br />5. Special handling conditions or other instructions: <br />0 <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( ) If NO, explain: <br />QAC <br />Soil Other (specify): <br />T ? <br />Date <br /> <br />Page 8 of 8