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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample SOmiial S -? <br />C: P.O. Box 1750 .` S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 8121'3' Canon City, CO 8121Nucla, CO 81424 <br />Sample Loc./ID No. Lab. No.(s) i? <br />Sample Date lei, 2,-11 Time w <br />Collected By '' `-•- -:? <br />Field Cust*dan.. ?? - ..•?,,, . c : ;.. »--.... <br />Cotter Off Site Destination <br />Delivered By <br />Received By <br />Datq. Recd. <br />Time Recd. <br /> <br />..ses w <br />:e or, <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: <br />3. Field Data - Preservations:- t x?' ?g"t ?* ?•? r e y <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 <br />QAC <br />) NO( ) If NO, explain: <br />Date <br />w <br />