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CO'T'TER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S 25282 <br />_ <br />C: Y.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 Luc./1D No.. 5 ?_S Lab. No.(s) <br />Sample Date J/ - U ' Z "/ ?? Time s Date Data Entered <br />Collected By _ ?? rPr.? r Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />C <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd, <br />otter Off•Site Destination <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />c <br />1. Sample Type: Air Water Zll Soil Other (specify): <br />2. Analysis- Test series requested: <br />3. Field Data - Preservation: f f? . 0 •2 S r. <br />ME A <br />Q.?LNG <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 /> <br />Date <br />Page 40 of 43