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COTTER CORRORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 112 s 47 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. <br />?F <br />Sample Date 4- 0S -/o Time ' 44- <br />Collected By <br />r" <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />V V L?CC varo?sc +?cauua?.v„JI <br /> <br /> <br />// ?? 7 <br /> <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />.Laboratory Destination if not Cotter: <br />sN <br />Sample Type: Air Water -r Soil Other (specify): <br />Analysis - Test series requested: r5 15 <br />3. Field Data - Preservation: <br />4. <br />5. <br /> <br />Date analysis required by (if not Holding Time): <br />Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial/( ) and explain below. <br />` <br />COMMENTS - Explanation of noted items: A e <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( <br />QAC <br />) NO ( ) If NO, explain: <br />Date <br />r <br />1 M1. <br />r <br />_.._.-. -..Page. 6--of6 <br />