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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Canon City, CO 81215 Caiion City, CO 81215 <br />Sample Loc./ID No. 96t/ 9 /Z Lab. No.(s) _ <br />Sample Date i/flTime <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a u«c■ <br />vu -oast ucoawaaivia <br />rt <br />1. Sample Type: Air Water <br />2. Analysis - Test series requested: i <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />N. G t.� P <br />v <br />Soil <br />?0 <br />c <br />3. Field Data - Preservat on: <br />4. <br />5. <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />Other (specify): <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 />561r, , <br />Page 9 of 9 <br />