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Sample Date ` Al -gal/Time •,, ' s <br />Collected By a 4 TO /Iv " ' . . <br />Field Custodian [P ii A_ <br />Cotter Off -Site Destination <br />Delitvered By , q4 .'."`4 1 <br />Received By . P Er' 1 <br />Date Recd. <br />Time Recd. . <br />COTTER CORPORATION SAMPLE SUIMITTAL AND <br />Sample Submittal .? :S 25724 <br />C: . P O. Box 1750 S: <br />Canon. City, CO 81215 <br />Sample Loc:LID No: <br />TRACKING FORM <br />P.O. Box'; 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />L,b. No.(s) <br />Date Data Entered - <br />Dita Entry By <br />Laboratory Destination if not Cotter: <br />F""✓�",*` ZG a D ar- a CJr <br />r "V. 2 <br />6*if 4e <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis =lest series requested: r� £if 2. <br />Field Data — Preservation: ,f i 1` " f .1! z g 0 A " <br />a l / I F y /4.40* i="4 HAI 4 2x f <br />. f I I- U./,/1 " 3 04, 5 ;s,...t.,9 <br />platinalysis required by Of not Holding Time): <br />handling conditions or other instructions: <br />6. Invalig circumstances? If YES initial ( ) and explain below. <br />COMMENTS - Explanation of noted items: <br />( )4.r Check if additional attachments. <br />QA Revie+i: <br />Sample valid? YES ( ) NO ( <br />QAC <br />If NO, explain: <br />Date <br />