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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 4-R? 5 7 K <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Caiion City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample LocAD No. Lab. No.(s) <br />Sample Date j ;-?2 Time 1300 <br />Collected By >,.. . _ _ <br />s? <br />Field Custodian r' r ., .. <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.vcLCr vii-OiLC V"UUBLIOU <br /> <br /> <br /> a <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />-7 <br />LE'---??s??c.l?•-less ??L'Z <br /> <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: 4 ? <br />C' C' <br />3. Field Data - Preservation: T 7 77 o q ?. c "/Z <br />v /it. c o 2. S <br />S ? J!f - 62 L ' <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 34 of 39 <br />