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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i It! 52637$ <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample I.oc. /ID No. S #4 'i 6 Lab. No.(s) <br />Sample Date $ '/ " /2 Time /1 • DO <br />Collected By ASO 6 �"�+ <br />Field Coltedian & 4 re,' l C <br />Cotter Off -Site Destination <br />Delivered By Ad‘ ft;., /4,1 'y <br />Received By fr 4' /m[ i',- NOA- <br />Date Reed. a- <br />Time Recd. <br />1. <br />Date Data Entered <br />Data Entry.By <br />Laboratory Destination if not Cotter: <br />1. Sample Type: Air Water / Soil Other (specify): <br />2. Analysis - Test series requested: �ei b 1 <br />3. Field D - A Prese )s r`vation: '(] r c / � � �1 •.�g /�y/�,�/ �, <br />1 t f /6! di f",4 0 2 /I'fA ' O 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 />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC <br />Page 28 of 29 <br />