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1..V61Cl <br />a 1W1 <br />- I e e3 mt <br />44_To <br />A <br />F - <br />._ - <br />!te <br />-I -1 <br />a. a <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />'' S <br />Sample Submittal r 251 62 <br />��_ . <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Canon City, CO 81215 Canon City, CO 81215 <br />Sample Loc./ID No. 5t) - 4 to # Lab. No.(s) <br />Sample Date ? - � 20 Time / 3 00 <br />Collected By ;� ' 6 71.-4 / G t <br />Field Custodian .6 o T�.�•.✓G <br />Delivered By <br />Received By <br />Date Recd. i <br />T Recd. <br />S <br />Off ' t D t <br />Time <br />ec o., S <br />1. Sample Type: Air Water 7 f Soil Other (specify): <br />2. Analysis - Test series requested: L /� <br />CO S s <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />A/ P•--5 y Zr., X c. G save P s .L .i. <br />2 fr H / <br />■--/7 r ,, Gay. &' (G a/ <br />3. Field Data - Preservation: t ` /7, 0 p # O . ! C; 3 / <br />/ f A # A/ 0 ? 0 <br />I L r,/..z 5 a c, F A .y /t/ 0 .�. -� / C- U, <br />tar A /7', (99 � ,�.., �. 5 � L ui / < G ' // 1.5 <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 />COMMENTS - Explanation of noted items: <br />( X ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC Date <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Page 27 of 29 <br />