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jr, <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal .,`2 S Z??'M <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 />Sample Loc./ID No. Lab. No.(s) <br />Sample Date -;t -/ - j rime )D S` <br />Collected By J-30 <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd..:= <br />VVLIol vaa-oleo LiDSUaawV? <br />F ?z,L\ <br /> <br /> 1 <br />Date Data ]Entered <br />Data Entry By <br />Laboratory Destination if not Cgtter: <br />a4 <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested:6 .f? <br />3. Field Data - Preservation: + `? l ` "`' + f t <br />t y;r K'33 S7 <br />4. <br />5. <br />A/ S 6; <br />Date analysis required by (if not Holding Time): <br />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 />