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Q <br />-COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S <br />P.O. Box 1750 S: P.O. Box 1750 N: P.O. <br />CaSou City, CO 81215 Callon City, CO 81215 Nude, CO *UP" <br />No. <br />Tr T- <br />Lab. No,(#) <br />Date Data Entered <br />Data Entry By <br />4- <br />Laboratory Destination If not Cotter: <br />4r <br />I:WSWW4r <br />V111-011tc imunguon <br />Air Water Soil <br />Other (specify): <br />series req uested: <br />ZCOZ <br />-t <br />c4rcumstances? H*" Initial and explain below. <br />Wif"nation of noted Items: <br />Mr�'` <br />ff additional attachments. <br />4AA—, <br />pie did? YES NO If NO, explain: <br />QAC Date <br />q7 <br />o admt- ' a m <br />s�m w '*tii z c v t-w ' <br />Air Water Soil <br />Other (specify): <br />series req uested: <br />2.9 -7 <br />7 <br />rvation: <br />required by (If not Bolding Time): <br />editions or otbqw instructions: <br />-t <br />c4rcumstances? H*" Initial and explain below. <br />Wif"nation of noted Items: <br />Mr�'` <br />ff additional attachments. <br />4AA—, <br />pie did? YES NO If NO, explain: <br />QAC Date <br />q7 <br />o admt- ' a m <br />s�m w '*tii z c v t-w ' <br />