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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal • rt S Mtn 1 <br />: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample LocJID No. S- a b f <br />3. Field Data - Preservation: ! 7. S e <br />r/H e.Q.V. .•9. <br />IL /' 1. :S' ° UP,, / vei l <br />S -A a. 5 L lefic t/ 72 <br />4. Date analysis regUired by (if not Holding Time): <br />S: PO. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Nadia, CO 81424 <br />Lab. No.(s) <br />Sample Date 7 t 2 7 11 Time / O. r + r 5 Date Data Entered <br />Collected By L 4h 7i c w Data Entry By <br />Field Custodian /.. o4 7P,rvn. ¢ 440 Laboratory Destination if not Cotter: <br />Cotter . Off -Site Destination P,w tom g 99 14 h . 0 •r c from , 401, . 7,• <br />Delivered By 4 5 rPyv t�CI4X 2193 3 if C;reeqt lfiC,./ S� , <br />Received By P/? f V C. e. f' «•i i id - s Z C al <br />l <br />Date Recd. 1 <br />Time. Recd. /° an ( ,,v / <br />1. . Sample Type: Air Water <br />i Soil Other (specify): <br />2. Analysis - .Test series requested: �a I. 4! <br />7 . 7 7 ( I 7 l 5 <br />I to s At 1. � , / A1V a Z0,4 <br />/ C1l / : / /L /fA# <br />S. Special handling conditions or other instructions: <br />6. Invalidating circutustances? If YES initial ( ) and explain below. <br />COMMENTS - Explanation of noted items: If 44 I / /to, <br />( .x ,) Check if additional attachments. <br />QA Review: <br />Sample valid ?.. YES ( ) NO ( ) .it NO, explain: <br />Date <br />Page 34o# 39 <br />