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<br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal VIII!, 5.:+66 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cagion City, C0 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. o <br />Sample Date 1-421-070V I Time /3A 0 <br />Collected By ' <br />Field Custodian 4 <br />Delivered By <br />Received By. <br />Date Recd. <br />Time Recd.. <br />1. Sample Type: Air Water <br />2. Analysis ?- Test series requested: I <br />3. <br />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 clreutmItances? If YES initial ( } and explain below. <br />COMMENTS - Explanatien of noted items:. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) 'If NO, explain: <br />QAC Date <br />- Page 18 of 20 <br />Lab. NOS) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />2 393 S? hF ` G'0 P e te h? 4/, e . <br />el ?(gz AZ '. 27. 1.1 <br />o <br />Soil Other (specify):