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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />C: P.O. Box 1750 S: . P.O. Box 1750 N: P.O. Box 7 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO'$1424 <br />Sample Loc./ID No. D Lab. No.(s) T_ <br />Sample Date Via(" ' .? 'i+ Time ? ^ y t i.r Date Data Entered <br />Collected By # r ,... Data Entry By `-? <br />Field Custodian. Laboratory Destination if not Cotter: <br />%.vaaci <br />?rr ",'".ac VC59INNUUM <br />It .7 <br /> <br /> <br /> <br />h ?J <br />_ h1; <br />:1. Sample Type: Air Water ? Soil Other (specify): <br />2. Analysis - Test series requested: r? f iiy?'.• .--I ._?^?_v <br />Delivered. By <br />Received By <br />Date Recd. <br />Time Recd. <br />3. Field Data - Preservation- 'e <br />?L, <br /> <br />4. Date .knq'T fdred by (if not Holding Time): <br />S. Special Kailirig.FQpilitions or other instructions: <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 />Date <br />.. Page 6 of: fi ;.