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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal l? 2 3125 <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 Loc./ID No. 10 S 40 1A Lab. No.(s) <br />Sample Date I / - /U .2 4/V Time Pa, 'Is t <br />t (- <br />Collected By ?°??•/ <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />3. <br />4. <br />5. <br />y-LUiLCI <br />U / ?/ vT vu-r7uc uc.?uua?ava <br /> of <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />ND/ <br />O 4 <br />Sample Type: Air Water ? ~ Soil Other (specify): <br />Analysis - Test series requested: -re- L /,e :K <br />Field Data - Preservation: <br />f <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial <br />COMMENTS - Explanation of noted items: <br />( x ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( } NO( ) If NO, explain: <br />QAC <br />Date <br />Page 22 of 23 <br />) and explain below. <br />