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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S 2 5 K 5 2 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 8121S Nucla, CO 81424 <br />Sample Loc./ID No. D K-5. D 41A <br />A 22/27 <br />Sample Date 1.2:w. '? 00 Tim %; <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />?! vva.ca <br />'Yn..?. G •,t,J vu-oltC LCSU MIUM <br />C? t i G ?j' <br /> } <br /> <br /> <br />Qz <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />4.. <br />1. Sample Type: Air Water .} Soil Other (specify): <br />2. Analysis - Test series requested: ris <br />3. Field Data Preservation: C?c3., ?, s i f t rC' fJ / L G/F .Q c 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 ( ) 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 6