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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal "'2 2 5 4 7 6 <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. Dr ? 0,-) / A Lab. No.(s) <br />Sample Date Time <br />Collected By Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />IJVLLCf Vu'OLac vc?s?uauou <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />r <br />Q?N 11 <br />( 6 ^1 <br />1. Sample Type: Air Water Soil other (specify): <br />2. Analysis - Test series requested: T^ h / 17 <br />3. Field Data - Preservation: all 7 ,-! 7 <br />II / f V ?l ? ? [ t '` G ?"t S c y l e..t •ti ? -- r i . G Ct /^ ? ) `, ? ?f ?-a" <br />7 <br />0 S ti/`'? ? <br />P, <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 />Page 23 of 23 <br />