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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 2 S 2 5 5 5 6 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Canon City, CO 81215 Canon City, CO 81215 <br />Sample Loc./ID No. ! / IT U Lab. No.(s) _ <br />Sample Date Time 41 20 <br />Collected Byre <br />Field Custodian 1-1!fd <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />l.U?lCi Vll'OIIC YC6HQiL L1Vtt <br />1 5 <br />fY <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />laz/ <br />X <br /> <br />G'..0 <br />1. Sample Type: Air Water / V Soil Other (specify): <br />2. Analysis - Test series requested:- <br />3. Field Data - Preservation: . y , 3D <br />/7 e <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 <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />••,e:... _..-v. .w .s ?rs ': "•s? _ ?. ? _ ? me