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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S 25124 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. .2w,4 DU / Lab. No.(s) <br />Sample Date Time <br />Collected By ?????? <br />Field Custodian j3o To...n. r <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />?.vaaca vaa-ORC uc?uuauvu <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Fete LC 4 oiG f 0' SII/C. <br />y o/ <br />U. <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: <br />3. Field Data - Preservation: <br />3.11 <br />St?? 1,3' <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 />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( } If NO, explain: <br />QAC <br />Date <br />Page 14 of 20 <br />) and explain below. <br />