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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ?Y2 ? t, S4j?2 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canun City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S (-<--j /T 0._5 Lab. No.(s) <br />Sample Date 2 7 `?aiJ Time 1 L/ 3 S Date Data Entered <br />Collected By Data Entry By <br />Field Custodian 1 Tim r•••v n Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Reed. <br />Time Recd. <br />?.v??ci v?uJ-auc vcryuunulvn <br /> C51.. <br /> <br /> <br />L? <br />1. Sample Type: Air Water 1 Soil Other (specify): <br />2. Analysis - Test series requested: (n '/o <br />3. Field Data -Preservation: r oc, 11, S i 9 /-/I 'y 80 <br />:-/ <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 { <br />COMMENTS - Explanation of noted Items: <br />) and explain below. <br />( } Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />Date <br />Page 18 of 20 <br />