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Sample LocJID No. <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />C: P.O. Box 1750 S: <br />Cason City, CO 81215 <br />Sample Date g ` Time 0 ; 3 S� <br />Collected By c 4 IP A/ +✓' r <br />Field Custodian £ o , R' 4,�✓c A, <br />Cotter Off-Site Desti ation <br />reaS- Fed‘t - Grp <br />p -�- � <br />11 s� <br />Coa <br />Sample Type: Air Water 6 Soil Other (specify): <br />Analysis - Test series requested: f4 4. /e <br />3. F i e ld Data - Preservation: 7 6 1f / I / 4, 9 s . (M,vd. f f 5 1 w s 0.44-0 - <br />r /Ai s e d 1 7, 2 s" s • 4 :0 red X1.9s +' <br />/e FA /Kt/4 a ,. / �. " /G W � AD 3 g 'JO <br />Z tof` I2 /Alf y 5 <br />4. pate analysis required by (if not Bolding Time): <br />5. Special handling conditions or other instructions: <br />6. IntaKdating circumstances? If YES initial ( ) 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 <br />Sample Submittal <br />/4-q "4101: (t <br />'<YIP <br />112 s 25174 <br />P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />393 e! k <br />�'-6 -1 �y � >■ 8 z.Gc o <br />— Page - 21 of 23 <br />