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i <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i iZ S Z6! 12 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. W 14 w /2 Lab. No.(s) <br />Sample Date 1/ " 1 7 13— Time / J y`• <br />Collected By L 5 TA -� ' f <br />Field Custodian dc <br />c <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />l,.UILCi- <br />fs <br />vai�o■�c Lcaa■ua�■vu <br />1. Sample Type: Air Water <br />2. Analysis - Test series requested: <br />3. <br />i <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Colter: <br />r f <br />z-27�� �f rr���t" �'.e <br />�. f.� Lt/ 5! S 7(� 01 <br />l3 <br />J N <br />Soil- <br />Othdr (specify): <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial <br />COMMENTS - Explanation of noted items: <br />) and explain below. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC Date <br />