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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal _ . 2 S IM1111 <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample Loc. /ID No. "l �'j _ cc? <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />��33 <br />Sample Date "A' 7U - Time t <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />VVLLCC <br />Vll'OILC LGDL[LLALIVV <br />2- <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destipatio((n if not Cotter: _ f <br />{ <br />,;,.- :• c.,/ -� � ee i � �,._ � tom` < < � � Y✓ / <br />7 <br />Q <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis — Test series requested: < C "br- 1 <br />3. Field Data — Preservation: F <br />4. <br />S. <br />..I `'�.. 0-7 <br />Date analysis required by (if not Holding Time): _ <br />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( <br />QAC <br />) If NO, explain: <br />Date <br />14 of 16 <br />