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ample LocJID No. 5 14. / Pic <br />Sample Date -/ -2t? 0/ i / :3 S — <br />Collected By 112 7 !.4d . dzt _ <br />Field Custodian fin / �.✓.�/f r✓ 7 <br />Cotter . Off-Site Destination <br />Delivered By w,ve <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water / Soil Other (specify): <br />2. Anaiysis Test series requested: <br />3. Field Data — Preservation: f o g s ", <br />S ‘C <br />4. • Date analysis required Of not Holding Time): <br />S. <br />COTTER. CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />C: P.O. Box 1750 <br />Cation City, CO 81215 <br />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 />Sample Submittal <br />S: <br />QAC <br />S257O4 <br />P.O. Box 1750 N: P.O. Boa 700 <br />Cafion City, CO 81215 Nucla, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Labpratory Destination if not Cotter: <br />2 $ ' s e e.e Q k �Twc�r► <br />�u c p o-, le/y_ 2 2c e a. <br />r <br />S - g . 5: FA 11 A^. 5 ..... <br />and explain below. <br />) If NO, explain: <br />Page 15 of 20 <br />