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<br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />:Sample Submittal -0 s 86 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion City,-CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample LocAD No. 1 . Lab. No.(s) <br />Sample Date' Time 5- <br />S ..p.?..?c <br />Collected By A0 <br />Field Custodian . 6 o.4 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />LOLICi" Vll'?7AC LWHnnslun <br />v ` ;- lit' <br /> <br />-c • u . ? <br /> <br />1. Sample Type: Air Water <br />2. Analysis - Test series requested: _ <br />3. Field Data - Preservation: f 7.0 "g117,70 ?, 2 a <br />4. -Date analysis required by, (if not Holding Time): <br />5. 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 />Date Data Entered <br />Data Entry By <br />Laboratory Destination If not Coll er: <br />N <br />-T <br />23 ?? sc / ? Cr,r Q ? ?wy. <br />'l Li <br />?y <br />Soil Other (specify): <br />Page 16 of 20