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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal Ni°_ S IS i 37 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Callon City, CO 81215 Canon City, CO 81215 <br />Sample LocAD No. ?aI Lab. No.(s) <br />Sample. Date 3 °? ° ''?Yme ?a ` d S? <br />Collected By 16 O 4?P.?r? G .v <br />Field Custodian 904, ? .??? ? ?1111 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />??(( //a,u&tcr V11?O.?i LiDYLiMVu <br /> %IACJW <br /> <br /> 3- ? <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />3 P c? <br />S7 «- G?! 2 9 o <br /> <br />1.. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: t <br />3. Field Data - Preservation.: <br /> <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 />QAC. Date <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />