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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal N`2 S 5 6 2 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Cafion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. -fu Lab. No.(s) <br />Sample Date Z` 2 512 d E/ lime 9:( a <br />Collected By S 7P <br />Field Custodian 1'd a 4 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Field Data - <br />\.VLLCC <br />loo vii-oLLO LliDUnativu <br />feel lek <br /> <br />•? S -? d/l <br /> <br />G1. Sample Type: Air Water / Soil Other (specify): <br />2. Analysis - Test series requested:, <br />3. <br />4. <br />5. <br />7 o c, <br />0 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />.-7 <br />r_ so-.c (,i /1_4 J., G " Ir , s rti C , <br />233 a./# «? <br />,?00 MS <br />CT <br />r A S. <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 />( X ) Check if additional attachments. <br />QA Review: <br />Sample valid? <br />YES ( ) NO (. ) If NO, explain: <br />QAC Date <br />