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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal s 244414 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. 5 'f <br />Sample Date L! ` .% Time �-- --f <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />%- ULLCI" <br />VI1-01LC uCbNUALROU <br />F� ]t <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis — Test series requested: e t :IC <br />3. Field Data — Preservation: i- #�•V F' �' �' ' �l� '�' J t C� <br />f •^ , 0070 <br />4. <br />5. <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial <br />COMMENTS — Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( <br />QAC <br />) and explain below. <br />) If NO, explain: <br />Date <br />Page 16 of 16 <br />