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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal l S g$ <br />C: P.O. Box 1750 S: RO. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. Lab. No.(s) <br />Sample Date 3' -;Nr// Time'1 `1J'5 .- Date Data Entered <br />Collected By '`.iData Entry By <br />Field Custodian is J4' <br />Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Cotter Off-Ste Deshnahon <br /> <br /> <br /> <br /> <br />V. o 2- <br />If <br />r <br />1. Sample Type: Air Water, Soil Other (specify): <br />2. Analysis - Test series requested: 1r.0 4 <br />.:. , . <br />3. Field Data - Preservation: 41 <br />4 <br />/ ',° •'~.r-; .e':+ h _?? '? ?;_?: iA, "a. fr r`t. ?• F ?`.r • / (y'j7 j_?.- y?.z! _?I-? -".+r/?'t <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 /> <br />QAC Date <br />.:?.?.?.?._..? • ..W._..? .. .. ? ??x:,- .?.?? - - ?....?. .. ? fag ?3of36 - . <br />.