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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal sS ISM <br />C: P.O. Box 1750 S: R0. Box 1750 N:. P.O. Boa 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. ? Lab. No.(s) <br />Sample Date 4? - 16-1" oif Time Date Data Entered <br />Collected By Data Entry By <br />Field Custodian A - Laboratory Destination if not C,+otter: <br />Off a.&. Dent' tl ? z I • : 'r 7 e <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Cotter -ate un on <br /> <br />t' <br /> <br /> <br />r r <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: 3ell?? <br />X, Field Data - <br />4. <br />5. <br />6. <br />COMMENTS - Explanation of noted items: <br />i; <br />Date analysis required by (if not Holding Time): <br />?:... <br />Special handling conditions or other instructions: <br />Invalidating circumstances? If YES initial ( ) and explain below.. <br />( ) Check if additional attachments. A <br />QA Review: <br />Sample valid? ES ( ) NO ( ) If NO, explain; <br />- a <br />QAC Date <br />