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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ►, S 25794 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 �J <br />Sample Loc./ID No. 5c/ G S <br />Sample Date 5 3 1.,'// Time / /S <br />Collected By /O ( a -t. 7 <br />Field Custodian 7x°."- w <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 />Cotter Off -Site Destination <br />Y P.� Lc +S ii.✓D r / P Sim c. <br />Delivered By 40 4?-vrve -J 40e301 7313 " c f7 (r P <br />Received By , 1 1 4 0 4 / . . " l - </t- a.. , C( a 7 C 0 <br />Date Recd. 2.S 1 1 <br />/00D Time Recd. <br />f a 0 ,a. -• <br />1. Sample Type: Air Water / 6 Soil Other (specify): <br />2. Analysis — Test series requested: (Ode r dr l <br />Field Data — Preservation: r 04 7 4 / / 7. 75 , 6 A -di 2 ZS- <br />0_0 <br />.- e Z. D G. S di , 4. S L r"/'r / //V/ 3 <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />6. luvalidating 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 />