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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S 2660-0 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 91215 Canon City, CO 81215 Nuiel6, CO 81424 <br />Sample. Loc./ID No. l 11'/ f S?--- Lab. No.(s) <br />Sample Date Time 4.. <br />,. <br />Collected. By j' ••+? r .? <br />Field Custodian A<")Q r <br />Cotter Off-Site Destination <br />11 ; t- Ic <br />Delivered By e /? '?? " <br />Y <br />?.: Received By <br />Date Recd. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />Time Recd. <br />I ti's" <br />1. Sample Type: Air Water Soil Other (specify): <br />r <br />2. Analysis - Test series requested: r*. <br />3. <br />Field Data - Preser <br />- <br />s <br />4. q. Date analysis required by (if not Holding Time): <br />.5. Special hantdliag, 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 />4 <br />M1 <br />6AC Date <br />