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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 1.2 S 2 671 3 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Canon City, CO 81215 Canon City, CO 81215 <br />Sample Loc./ID No. C Lab. No.(s) <br />Sample Date % - 21.1. - 20 ? Time <br />Collected By A(,) 4 '., 11 l Z <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />VVILCI <br />Vll'DIIC ilC�Il11A11V11 <br />11, 4 IV, <br />a3-�3 <br />Date Data Entered <br />Data Entry By. <br />Laboratory De. <br />A <br />- 't&,- r- <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: C: /"%e <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />4ination if not Cotter: <br />3. Field Data - Preservation:/ 7 ;) <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 19 of 19 <br />