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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S25$23 <br />C: P.O. Box 1750. S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Lab. No.(s) <br />Sample Loc./ID No. <br />Sample Date Time j <br />Collected By <br />Field Custodian •s {.-s'?+..+r? ..- <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />S.VLLEK vu-Ol\O 1JO19 HUMUVH <br />$5. 7-1 <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />/I se <br />rr :,, <br />.T N <br /> <br /> 1. Sample Type: Air Water r' Soil Other (specify): <br /> 2. Analysis - Test series requested: <br /> <br /> 3. Field Data - Preservation: 0 = ' .... , r E. <br /> L <br />*'IAJ 54? 4"1 <br /> <br /> <br />p <br />4. <br />Date analysis required by (if not Holding Time): _ <br /> 5. Special handling conditions or other instructions: <br /> <br /> 6.. Invalidating circumstances? If YES initial ( ).and explain below. <br />v <br /> COMMENTS - Explanation of noted items: <br /> <br /> <br /> <br /> { ) Check if additional attachments. <br /> QA Review: <br /> Sample valid? YES ( ) NO ( ) If NO, explain: <br /> QAC Date <br />-