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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal I ti S 25763 <br />C: P.O. Box 1750 <br />Cation City, CO 81215 <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. � Gfi A 4J/) Lab. No.(s) <br />Sample Date C . -)r,r 1 Time ©••10 Date Data Entered <br />Collected By /3 o lo Tra.v G ,i.: Data Entry By <br />Field Custodian 11 04 ,,,yc `"` Laboratory Destination if not Cotter: <br />Cotter Off Si Destination ) <br />Delivered By 7 ? '7 j r '7' f',. No ' L{ Cl •✓ f , <br />Received By (n ; ✓ - 1111 / g 2 4 0 2 <br />Date Recd. <br />Time Recd. <br />, ^' <br />1. Sample Type: Air Water / Soil Other (specify): <br />2. Analysis - Test series requested: Cp ,I, l <br />3. Field Data - Preservation: <br />7 - 2.7 X 11 7 q6 ( J 7 -S <br />,.,.. .2 7.. <br />s ' <br />411 1 n s /=4 AI/1/� • _ <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 13 of 20 <br />> `} c <br />11 to.,..,.e d <br />Al" ... <br />f !i <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal I ti S 25763 <br />C: P.O. Box 1750 <br />Cation City, CO 81215 <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. � Gfi A 4J/) Lab. No.(s) <br />Sample Date C . -)r,r 1 Time ©••10 Date Data Entered <br />Collected By /3 o lo Tra.v G ,i.: Data Entry By <br />Field Custodian 11 04 ,,,yc `"` Laboratory Destination if not Cotter: <br />Cotter Off Si Destination ) <br />Delivered By 7 ? '7 j r '7' f',. No ' L{ Cl •✓ f , <br />Received By (n ; ✓ - 1111 / g 2 4 0 2 <br />Date Recd. <br />Time Recd. <br />, ^' <br />1. Sample Type: Air Water / Soil Other (specify): <br />2. Analysis - Test series requested: Cp ,I, l <br />3. Field Data - Preservation: <br />7 - 2.7 X 11 7 q6 ( J 7 -S <br />,.,.. .2 7.. <br />s ' <br />411 1 n s /=4 AI/1/� • _ <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 13 of 20 <br />> `} c <br />