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C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample Loc./ID No. _56[/ <br />Sample Date 5 10 %20/ Time l y :4 ,s — <br />Collected By 1 Tti.0 c <br />Field Custodian j 7 ;<' "-• r✓ e: -' <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />Cotter Off -Site Destination <br />411111110 <br />Sample Type: Air Water / r Soil <br />T`G Ile / <br />2. Analysis - Test series requested: <br />!:' s 25784 <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />It ' <br />G{/y, 8ZC0Z <br />Other (specify): <br />3. Field Data - Preservation: T ' / / 3. <br />/ C. " Q3 2 <br />/ l 2 S l G1 FA' ' 0" 2 -,. <br />/ L / /AA 61 5 l� s ,�-� (9, > z_ ,ti4 X-27/ <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 />`1 //4S .73 <br />