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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal s26754 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. c-7&(} 4 14_1 r Lab. No.(s) <br />Sample Date / 2 - / F ' / /.- Time ) '_) c3 Date Data Entered <br />Collected By / Z ' 4 ri°4 ,-t c. -t / Data Entry By <br />Field Custodian /S0 A6 r 0-1--1 4%7 Laboratory Destination if not Cotter: <br />Cotter . Off -Site Destination /" r / te, e fr L ' o f -. 7!., - , - 7 .. <br />Delivered By L.�r) 1,'i 4 i r / r4', 011 2 ' ( ._a._ J/ '�,r e' c t% /9. v 2✓. <br />Received By f ', /,/ * 1 i f a q/ V_ S 2k <br />Date Recd. j <br />Time Recd. 1 d • ? f <br />n <br />4 ' <br />1. Sample Type: Air Water 1 ' Soil Other (specify): <br />2. Analysis — Test series requested: t' r_ rl." <br />3. Field Data — Preservation: r c'c y. 3 <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 />Page 7 of 8 <br />