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Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />s 25780 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Canon City, CO 81215 Canon City, CO 81215 <br />Sample Loc./ID No. .c /L <br />Sample Date S /0-,.20// Time / . Q s — <br />Collected By /Sd 7'0", <br />Field Custodian lq ra 4 /49...ti/r -1 7 <br />Cotter Off -Site Destination <br />' et <br />Sample Type: Air Water / Soil <br />Analysis - Test series requested: fig <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 ( <br />QAC <br />Sample Submittal <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />IO <br />• <br />Lie <br />23 <br />(Wdroo <br />Other (specify): <br />3. Field Data – Preservation: l '/o. 7 9 # - 15 `" ^"`'�' 'Z S c .-/ z <br />/, ' <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />) and explain below. <br />) If NO, explain: <br />Date <br />aye 4vv <br />e �– <br />