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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ; .' S 25278 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. 5?41r A (V p Lab. No.(s) <br />Sample Date ! ,' Time // 2 S <br />Collected By LSD 'NNe' ti <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /> <br /> <br />? l..UtLVI <br /> <br />,vr Ull-ouc vcotluaUUu <br />z <br />l <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />t <br />1. Sample Type: Air Water / Soil Other (specify): <br />2. Analysis - Test series requested:.. <br />3. Field Data -- Preservation: / ry ` /1. 6 _ , (2, T, e?5 c i <br />S? a ZA 41N0 , ? . I L A <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 --- Date