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S mple Date 9" - .2 0 # Time /3 c/ O <br />Collected By 60 rAs ..,. ' c <br />Field'Castodiaa.le 4 F .^�' <br />Cotter Off -Site Destination <br />APP <br />rip <br />C: P.O. Box 1750 S:. P.O. Bar 1750 N: P.O. Box 700 <br />Cahoa City, CO 81215 Canon: City, CO 81215 Nncla, CO 81424 <br />Sample Loc./ID No. 4 . 1 as - Lab. No.(s) <br />Delivered By <br />Received By <br />Date Recd: <br />Time Recd. <br />1. Sample Type: <br />• <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal •Ma .s 2570 <br />/ <br />Air Water 1 O • Soil Other (specify): <br />2. Aaalyais Test series requested: (Q/2 r <br />3. • Field Data - Preservation: r ' g riii . ef C5.-14 2 87 (04 er s I ' <br />/by s +2 - .e . 36 r,..4 44' r f 0. s 1‘.1/1 f .-..d . z . sT..�►�- <br />S ;IV <br />. Date analysis required by (if not Bolding Time): <br />5. Special handling conditloas or other instructions: <br />6. mating circumstances? If YES initial ( <br />COMMENTS - Explanation of noted items: <br />( . ) Check if additional attachments. <br />QA Reviety: <br />Sample valid? YES (' ) NO ( ). If NO, explain: <br />QAC <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination // d tt <br />if not Cotter: <br />: v P,r$' y 4 4 <br />.G ldv <br />8 2393. S 4A 6. .e #cy. <br />Jp .` , may: g260 <br />) and explain below. <br />323 <br />Page 19 of 20 <br />