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l.,1.1 Uri <br />vu-0111c ao awn <br />-% 4 <br />i <br />Q ,. <br />% a <br />/, <br />4 <br />0 <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 2 525793 <br />C: P.O. Box 1750 <br />Canon 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. 5 lc/ 05 Lab. No.(s) <br />Sample Date S 2 3 24w /Thee I 3 V 0 <br />Collected By <br />Field Custodian rf,c+ ,74 <br />Delivered By <br />Received By <br />Date. Recd. <br />Time Recd. <br />3. Field Data — Preservation: T 9 3 <br />fi e (77.4.. 2, 12 <br />...";" 2, <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />/'3 <br />7 3 `3 3 cc. r <br />4/ F ‘. o Z_ <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis — Test series requested: -1/40 / <br />2 /5 "u 544, <br />s / / 4 / O 7_ S- <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 18 of 20 <br />