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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal N5 R 25703 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample Loc./ID No. S' 1' A 00 / <br />Sample Date 4 .1 - -20// r ime <br />Collected By <br />Field Custodian 4 re/0•00/ 4" .4, <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Cotter <br />Off-Site Destination <br />1. Sample Type: Air Water <br />2. Analysis - Test series requested: <br />3. Field Data - Preservation: <br />ei/se 0 rp 1 <br />■ <br />/01 2.> <br />SY41 /, or <br />4. Dateanalysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />6. Invalidating circuMstances? <br />COMMENTS - Explanation of noted items: <br />( ) Check if addidonal aftachments. <br />QA RffieW: <br />Sample valid? YES ( ) NO ( <br />QAC <br />If YES initial ( <br />S: PO. Box 1750 <br />Canon City, CO 81215 <br />Lab. No(s) <br />0 <br />ov <br />Soil <br />Date Data Entered <br />Data Entry By <br />Labgatory Destination if not <br />L 44 try,se <br />2,393 c 4 .4 1 1 cr <br />1(.1 . <br />) If NO, explain: <br />) and explain below. <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Cotter: <br />t oe I OS A ft. <br />Sc <br />yr. <br />H , <br />Other .(specify): <br />• 0 60t 2 69 <br />L 4 H ids <br />. 0 <br />