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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 11-i": S its" <br />C: P.O. Box 1750 <br />Cafion City, CO 811�2tt15 <br />Sample Loc. /ID No. �-' L } i� <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Sample Date L 1 ::(' ' i Time V <br />Collected By <br />Field Custodian rf <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />%- VLLV1_ <br />V11-01M LJCa LLLLM&AVL1 <br />1 <br />9 U <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Des //((tination if not Cotter: j, <br />i i r <br />I, <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested:' -'tC. <br />3. Field Data -Preservation: <br />f r �`.� f����� a�� �J.��� v� � ,�•�1..� I� f -Jiffs: .�.� �� <br />4. Date analysis required by (if not Holding Time): <br />S. 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 13 of 16 <br />