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COTTER CORPORATION SAMPLE SUB1%4ITTAL AND TRACKING FORM <br />Sample Submittal N N r?15430 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon Cjty, CO 81215 Nucla, CO 81424 <br />S Lab. No.(s) <br />Sample Loc./ID No. a ? <br />Sample Date /6 )Time /S Y, eDate Data Entered <br />Collected By Data Entry By <br />r <br />Field Custodian Laboratory Destination if not Cotter: <br />Off S't D t' lion <br />Delivered By <br />Received By <br />Date Recd. <br />Time Reed. <br />Cotter <br />•,/y„'1+ ..Y ? .t I s e es saa <br />? .?\/ PSI {?L_.__ <br /> <br /> Il p <br /> R NS" <br /> <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: <br />3. Field Data -Preservation: 4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial <br />COMMENTS - Explanation of noted items: <br /> <br />_7.S_ <br />) and explain below. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC Date