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COTTER CORPORATION SAMPI„R.SIMMITTAL AND TRACKING FORM <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample Submittal <br />Sample Loc. /ID No. S <br />Off -Site Destination <br />W <br />s26633 <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Lab. No.(s) <br />Sample Date 9 - LL 10- Time / r.7 -. U Date Data Entered <br />Collected By /1.) r <br />Field Custodian 1 f, <br />Data Entry By <br />Laboratory /C� Destina tion if not Cotter: er: f <br />Cotter p�5 y , :- i Z .,. '',.A .. <br />' ../.... c <br />Delivered By /� - 4.1 7-- ',..1.- it .. f-e'.. ,� 2 3 S 7 4 c. t 7 - .) ,.. - f' e Gr . . , ,-- �/� * f . . <br />a tt r <br />Received By " - � f �,��'� <br />4- ��j� <br />nn 4I% 1 ?cc, r <br />Date Recd. �i <br />Time Recd. `�' <br />1. Sample Type: Air Water f Soil Other (specify): <br />2. Analysis — Test series requested: (.1 o e <br />3. Field Data — Preservation: r ` L / 5 7 / -3 P q' ,5 rte ^'•) 7 ev YO " ‹.,. ' i <br />w /,l 5 0 ., �..:1. 2. ?7, : >�,, -., ,'�' 5 f _ "(`) 5 C <br />0 C L J1 h'4/d .2 - S` -.. <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 . Date <br />Pogo 6 of C <br />