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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal _ i. Z S 2 5 3 9 6 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cadon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. D f S 0 :J/ A <br />Sample Date Time ?.- <br />Collected By <br />Field Custodian ?.-^.v.??, <br />Delivered By. <br />Received B <br />Date Recd. <br />Time Recd. <br />I.VbLGI VIl'OLLG LCSLIL'AIWL <br />j <br /> <br /> <br /> <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />o? <br />1. Sample Type: Air Water A Soil Other (specify): <br />2. Analysis - Test series requested: (- ?f .Z. <br />3. Field Data - Preservation: l / Z- <br />4. <br />5. <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 />) and explain below. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( <br />) If NO, explain: <br />QAC <br /> <br />Date <br />Page 6 of 6 <br />