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r COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal :2 5 2 6 4 3 9 <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. d T S Lab. No.(s) <br />Sample Date Date Data Entered <br />Collected By Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Delivered -tj c, 4V <br />Received By 4 dAc Qtmcg ! - .\Q2., <br />Date Recd. lp? c? <br />Time Recd. D <br />-160 <br />1. Sample Type: Air Water Soil Other (specify): <br />?s <br />2. Analysis - Test series requested: <br />3. Field Data - Preservation: <br />1 c <br />4. Date analysis required by (if not Holding <br />5. Special handling conditions or other instj <br />is: <br />6. Invalidating circumstances? If YES initial <br />COMMENTS - Explanation of noted items: <br />) and explain below. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC <br />Date <br />