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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ft° 5 25832 <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />SampleLoc./ID No. . S Lab. No.(s) <br />Sample Date 6' 7 Time , 2. 3 's' <br />Collected By <br />Field Custodian '' Q 4 161d, <br />Cotter Off -Site Destination <br />Delivered By <br />/304 144•6 t'i / &),- <br />• Received By _ fr''e/ %' <br />Date Recd.5 <br />Time Recd. , <br />Q4 <br />3. Field Data - Preservation: r ! 3 ,o <br />,ievsee_40 4'. do 1 ,4 5 eig.1 <br />QAC <br />4.14- iN P <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: ze.z <br />2393 jj scif te4.p / c✓y <br />ZO <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis. - Test series requested: !� ✓ v �'� . <br />e lf 7 .71 ^Jot 77duS J <br />Q . S / #4"'- ....+�► <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial ( ) and explain below. <br />COMMENTS - Explanation o f noted items: 'f' • h k e P'` s /2 . r rte <br />e rt r �. � c � /f4 f rl 3 <br />( ) Check if additional attachments. <br />QA Reviews <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />Date <br />Page 39 of 41 <br />