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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal " S r5W <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. _57 Lab. No.(s) <br />Sample Date Time q cl Q <br />Collected By S! -?? `?~ <br />Field Custodian / ! <br />Delivered By <br />Received By <br />Date Reed. <br />Time Reed. <br />a.vawr vaarouc ucsuuauva <br /> <br /> <br /> <br />/d? G? <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br /> <br /> <br /> <br />. <br />r <br />1. Sample Type: Air Water ?_- =soil Other (specify): <br />2. Analysis - Test series requested: / e <br />! /•(. i' ,' l r- / ; " <br />r 3. Field Data -Preservation: <br />At <br />Z e 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