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COTTER CORPORATION. SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ::2 S25671 <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 3-2 0 -,oZ Oil Time. <br />Collected By.Q ?f?.? <br />Field Custodian 61)S ra 1,14 Delivered By <br /> <br />Received By <br />Date Recd. <br />Time Reed. <br />%-ULLC[ <br />b P Gov Vaa?Olac ycoaaaaoaava <br />t o' <br /> <br />3r / F' <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />?tI('G/ 4 d b brG?d yio? ?,vc. <br />Z, 04, <br />41 <br />All ? Z(7, ooZ <br />,,f <br />?? Cdr <br />1. Sample Type: Air Water. Soil Other (specify): <br />2. Analysis - Test series requested: 4 A- <br />3. <br />4. <br />5. <br />Field Data - Preservation: <br />6. Invalidatiug circumstances? If YES initial <br />COMMENTS - Explanation of noted items: <br />() Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC <br />) and explain below. <br />'r f- <br />//7, 3 ,-? <br />Date <br />Page 23 of 24 <br />Date analysis required by (if not Holding Time): <br />Special handling conditions or other instructions: