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C: P.O. Boa 1750. S: P.O. .Box 1750 <br />Canon City, CO 81215 Cafion City, CO 81215 <br />Sample LocJID No. la A 41 0 Lab. No.(s) <br />Sample Date it /2 -20,I Time . j OS _ <br />Collected By IS 04 7'o, , I/ <br />Field Custodian A v Z. 1P ►'vim e ^1 r <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water Soil Other (specify): <br />/_ <br />2.. Analysis - Test series requested: `- Q t/49 <br />3. Field � •. <br />eld Data - Preservation 1 s. 3 4 • IS "�� • 2 6 7 u `' �' z . > <br />e_ e.), 2.14 c -e r . O. s`L f4ffQ <br />. Date 'analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <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 />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal s 25702 <br />QAC <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />y 0/4 7,7r i ra S j.v f . <br />23 4 7S S r e e Gf 4 <br />1413 g.2 66(2,. <br />) If NO, explain: <br />) and explain below. <br />N: • P.O. Box 700 <br />Nacla, CO 81424 <br />Page f3 6fi 0 <br />