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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />? t 111 Sample Submittal : SM <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Canon City, CO 81215 Canon City, CO 81215 <br />Sample Loc./ID No. 10 . 0 Lab. No.(s) - <br />Sample Date 27 Time / 4/ <br />Collected By f' "•' ?' <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />W-ULLef vaa•vaa? a+w..••»••?--// <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />1. Sample Type: Air Water r Soil Other (specify): <br />2. Analysis - Test series requested: 2- <br />3. Field Data - Preservation'. <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 />ry <br />QAC <br />Date <br /> <br />N: P.O. Box 700 <br />Nucla, CO 81424