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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 5 2 5 6 4 7 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Canon City, C/O 81?2?1/5 Caiion City, CO 81215 <br />Sample Loc./ID No.. l "r W " Lab. No.(s) _ <br />Sample Date =• 2 0(/ Time <br />Collected By r O ?".vi? ?' ?- <br />Field Custodian g a ?, 7p iv ?? G -. j <br />Delivered By. <br />Received By <br />Date Recd. <br />Time Recd. <br />?.+/.V//LCCf /? <br />?? f /??vf V Vll'OAO a/oasifu/tea ry?Vu <br />?? f..? /a <br /> <br /> <br /> 3 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination/ if not Cotter: <br />uri<S INC. <br />-23 I3 v /r?? ?rc e k . <br />G S ?.. 4 Z. 6 a,Z, <br />% <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: ra z fem. <br />3. Field Data - Preservation: <br />4. <br />5. <br />2 L Afi= l /- Z' " tf2 "? (9 ?/ s "Y <br />Date analysis required by (if not. Holding Time): <br />Special.handling conditions or other instructions: <br />6. Invalidating 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 />N: P.O. Box 700 <br />Nucla, CO 81424 <br />) and explain below. <br />QAC Date