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0 <br />COTTER COR1tQRATION $AMrIX NUBMITTAL AN]R WRACKING FORM <br />$41MRIe 261 to <br />C: RO. BAx 1750 iRO, VAx j75Q N: ]KOt Bain 74o <br />Canon City, CO $1215 0004 C #ty, CQ $1215 NRCIa, VQ $1414 <br />Sample Loc./ID No. �i�t (.d D <br />sgppje pate Tie <br />CAllectetl By <br />Field Custodian &I e� ZP ., <br />Delivered Ry <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />3. <br />4. <br />4 <br />.. ... j <br />- Alf W3, AlRall" <br />) <br />11;2z <br />]Rate Nta Entered <br />]Ra!a Batry By <br />1•$4toratgry 1llestin$tion ii' nat CattFr,•: <br />Sample Type: Air Water —L-�� foil Ather (specy); <br />Analysis — Test series requested: �� f <br />Field Data - Preservation: <br />_ A , <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( ) If NO, explain: <br />QAC <br />Date <br />Page 7 of 8 <br />