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%...1.11.1C1 4 <br />4 .111 . 011Z H <br />es / <br />H <br />/ na t <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal N2 S 26795 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample Loc. /ID No. <br />Sample Date 2 -19 ' f Time / 0 5 5 <br />Date Data Entered <br />Collected By /I.,' `� / �` /� C " 1 Data Entry By <br />Field Custodian : '. .. •n r `' Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Recd. <br />Ti R d . <br />' D ti <br />3. Field Data — Preservation: 7 c ( 2 . V <br />S: P.O. Box 1750 N: P.O. B 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Lab. No.(s) <br />• <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis — Test series requested: /0 1' <br />, /7 7 3 � �. ,_ , • � 9 S� rA 5,, -1 <br />s •� <br />(, G 4 / /Al a 2 , <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 8 of 8 <br />