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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal r 21422 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, C?O^ 81215 Canon IQty, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. J ul'1-14 Lab. No.(s) <br />Sample Date 11 -16 2 - `1 ? Time ;Date Data Entered <br />Collected By Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Reed. <br />?.u??er Vll?Ol{C LGSU1{7{HVU <br /> <br /> <br /> <br />uO <br />, N <br />1. Sample Type: Air Water 11 Soil Other (specify): <br />2. Analysis - Test series requested: r <br />t -- 1 -? .? <br />3. Field Data - Preservation: l d/ ?? `? 1• j?' n*c' • 44 <br />0, ? Z -IA <br />7. 5 <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 <br />) If NO, explain: <br />QAC Date