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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />S <br />Sample Submittal � :_ . 25868 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample Loc./ID No.. la g L <br />Sample Date 17- 9 + °i Time •19 S Date Data Entered <br />Collected By dJ r > Data Entry By <br />Field Custodian . S a 4 T e t <br />Laboratory Destination if not Cotter: <br />Cotter Off -Site Destination ,,_ ✓`a t, L c.• 1 . d ., G d ## .; ;;r ! .( 1.R. c. <br />Delivered By _ �_ 1 - r' 3 9 . . ' 4 i, C e e 4f # . <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water Sod Other (specify): <br />2 . Analysis - Test series requested: ` ....- @ / <br />3. Field Data - Preservation: ! <br />T : ....Cif. /. ? r' <br />6. Invalidating circumstances? If YES initial ( <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion City, CO 81215 Nucla, CO 81424 <br />a <br />Lab. No.(s) <br />7 ( 2 .f <br />t t / / C.�, t , ,..Y f` <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />) and explain below. <br />COMMENTS - Explanation of noted items: <br />( ) Check If additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC Date <br />f -: <br />