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1-.111.1V1 <br />VLL'OLLC LWLIu4IIVL <br />,, t <br />riziL <br />WE <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />s16793 <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. > ` -Tf /9 D Lab. No.(s) <br />Sample Date ? • i / 5 Time / C? r Date Data Entered <br />Collected By i ' �. -' . -t 1 Data Entry By <br />Field Custodian 7 •� r , f Laboratory Destination if not Cotter: <br />�n P� y L Gj ..c. <br />2 rci e4-• /, <br />'. V. ( ( .- l <br />1. Sample Type: Air Water I r Soil Other (specify): <br />2. Analysis — Test series requested: f rJ • /i I <br />_ ' t c <br />3. Field Data — Preservation: ,r r / 1 , S .� /`'/ � ©/ v 9 2 I .,, <br />. /'t) (4, 4 ...f r °� ' l d , : / 7 // Z /v • y -T <br />Y,,< E' ti ," 7 L C � �� �� L /4' <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 />