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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal *'� S26887 <br />C: P.O. Box 1750 <br />Canon City, CO 8,1215 <br />Sample Loc. /ID No. f' /' / Z— z <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />C T-'- Lab. No.(s) <br />Sample Date D "� Time <br />Collected By ,frj�� <br />Field Custodian /� t (1 -,7 C <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />VVLLCi <br />Vll'OLLC L/C.l LIHa Llun <br />�i <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />1. Sample Type: Air Waters Soil Other (specify): <br />2. Analysis — Test series requested: -Dim <br />3. Field Data — Preservation: / `'� <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 ( ) 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 Date <br />Page 8 of 9 <br />