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COTTER CORPORATION. SAMPLE SUBMITTAL AND TRACKING FORM <br />r. X618 <br />Sample Submittal s <br />C: P.O. Box 1750 S: P.O. Box 1754 N: P.O. Box 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO.81424 . <br />Sample Loc./ID No: Lab. No.(s) <br />Sample Date/ Time <br />Collected By a/ ?.,?? <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />4Vll.C[ Vll'DIiC UCifUIIi/HUII <br /> <br /> <br /> <br />11? <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Z4 <br />7 If <br />1 k -T <br /> <br />C?•f. 454 <br />1. Sample Type: Air Waters Soil Other (specify): <br />2. Analysis - Test series requested: C:3st <br />3. 1 <br />4... Date analysis required by (if not Holding Time): <br />5: Special handling conditions or other instructions: <br />& 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 <br /> <br />) If NO, explain: <br />QAC <br />Date <br />