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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 1: S25299 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Caiion City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. Pf -S 00/'4 Lab. No.(s) <br />?04 - /<-7- G.. <br />Sample Date 3:-Z010 Time (01 o 14 (,-f Date Data Entered <br />Collected By a Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />%,oner vii-??•? L41L1..Y.avu <br /> <br /> r <br /> lo- <br />C- <br />1. . Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: LE-5- <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /> <br />3. Field Data - Preservation: ? C <br />4. Date analysis required by (if not Holding Time): _ <br />5. 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 />/1 o C- r /I <br />Date <br />Page 6 of 6