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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />C: P.O. Box 1750 S: <br />Canon City, CO 81215 <br />Sample Loc./ID No. <br />Sample Date S =23 2 e ) // lime 12 / 0 <br />Collected By � G f ��✓�*''�+'" <br />Field Custodian 04 7 °, % ,. .. / C <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Cotter <br />go S <br />jTP 0(E <br />s/ A53 <br />:12 s25790 <br />Off -Site Destination <br />' <br />/0 O C) <br />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 C tter: <br />F.A. 0, ZG !c O ✓ 4 roi / .v 5 % <br />(74 S - 4/y, c)Z Co <br />1. Sample Type: Air Water / Soil Other (specify): <br />2. Analysis - Test series requested: (fe <br />3. Field Data - Preservation: r* ` g ' . ' / � 6(7 8Y ^'� " 2/x L 5 ''`.' 1 <br />I' l�v 5 � P r .; �v <br />� ?.2Sc r „`` / ' f ?i' 7, < �,., <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 ( <br />) 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 />O /l sr o R4 <br />Para 1 ri of 9f1 <br />