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ILA; 11.11V1 <br />vu - oi►V araauu4UUU <br />/` <br />t, <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />C: P.O. Box 1750 <br />Cafion City, CO 81215 <br />Sample Submittal <br />Sample Loc./ID No. /-; <br />Sample Date / Z J ' Time <br />f � M <br />Collected By /.3' f 1 ' -1 <br />Field Custodian , °- <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />3. Field Data - Preservation: r <br />Z, Y2. <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Nucla, CO 81424 <br />/ I r <br />1. Sample Type: Air Water I (! Soil Other (specify): <br />2. Analysis - Test series requested: r <br />3. T <br />f <br />.1 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if pot Cotter: <br />5 <br />1- <br />QAC Date <br />,. L- I r., <br />4- / 4 '• iv . ;, 9 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 />Page 7 of 8 <br />X <br />