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C . . P.O. Box 1758 S: P.O. Box 1750 <br />Canon City, ' CO 81215 Callon City, CO 81215 <br />Sample LocJID No. <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 1! S MIS <br />Sample Date - 21'Z 1' / Time ! 3 ) <br />Collected. By AA S / 7 eel e r" <br />Field Custodian 4» C '1'- "r�+/4 « • <br />Cotter OftSite Destination <br />Delivered By ��iS.n-r44 <br />red <br />Received By " edtp <br />Date Recd. <br />Time Recd. <br />&A d1/ <br />1. Sample Type:. Air Water / Soil Other (specify): <br />2. Analysis - Test series requested: e.." <br />PAM Data - Preservation: l °4 /6. 8 fill 'Z C , N Z _z3 G S s •`. <br />e,wr 18S / O, . S- 4 PA 2. S <br />410 <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 />COUNTS - Explanation of noted items: de r" tie." , a:� i... <br />( ) Check if additional attachments. . <br />QA Review: <br />Sample valid? YES ( ) : NO ( ,) If NO, explain: <br />_Ceti s <br />QAC <br />N: ' P.O. Box 700 <br />Nncla, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotte <br />y . G-4. "t► 01 G. l ©i r M 9 I , <br />3 54.44 Ci -at e <br />ser A/Y, gA Z o Z <br />Page 38vf -39 <br />