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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal I r" S 25499 <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 Loc./ID No. g tc/ 6? S Lab. No.(s) <br />Sample Date 1- 1 c! :2di/ Time <br />Collected By <br />Field Custodian a, Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /> <br /> <br /> <br />10100 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cter: <br />?w,/? C to L 4 0/ 670 r iOS -rAIC. <br />2-3 S3 ?c ?f Cr P A- 1U7 (.'/ 4.- <br />y Tl?/B?d0 <br />40% P-1 I/ <br />N <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: r.a <br />3. <br />4. <br />5. <br />Field Data - Preservation: <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 19 of 20 <br />) and explain below. <br />