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a..ULLVI <br />vii -011.o J/CSHLLi1IIUl! <br />,d, 4 7234,vdr <br />roc eX <br />7- 3- i i <br />a.-szx <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ::2,s 25767 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample Loc. /ID No. t/ OS Lab. No.(s) <br />Sample Date S — ' 2 -?a/ / ° Time /d : /D <br />Collected By /../ <br />Field Custodian _ . /c- <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />575/ 1. Z z <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />e /, ,9 y 44c- � O O / �.� / S Tim C. <br />Cr G vt� <br />1. Sample Type: Air Water 1 Soil Other (specify): <br />2. Analysis — Test series requested: „la ( <br />3. Field Data — Preservation: 7 � 3 y "Ai z 7$' <br />r itis,0 r"1•4 -• S - , 7Y , " f w ( . 5 /`- /i/f/ Z, <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 17 of 20 <br />