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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ." S M128 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 8/12115 Canon City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. -!?,V /-n '? Lab. No.(s) <br />Sample Date - 9 %10/? Tie -/; 5 y <br />Collected By -ao 'L. <br />Field Custodian /Z - <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />l,p«Cr vu-sac Vcoawa?rvu <br /> <br /> t?- <br />Ip' .OU <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />P/ LG 0.4 ?t>. r F, I? c <br />2- 3 Aa. <br />F,_6 0, <br />..- <br />P1 1-1 <br />Sample Type: Air Water Other (specify): <br />Analysis - Test series requested: (Va 'Ie <br />3. Field Data - Preservation: -L <br />2. ,21? 739 <br />Y <br /> <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 /> <br />QAC <br />Date <br />Page 18 of 20 <br />) and explain below. <br />