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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal * S26466 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Caiion City, CO 81225 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. S (--'j e4 ,•�2 <br />Lab. No.(s) <br />Sample Date y: /0 - % j Time <br />Collected By 7';0,1 <br />Field Custodian'CS.�.: J. <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />...vaaca <br />vi, -que Lesunauon <br />E <br />1. Sample Type: Air Water,� -; Soil Other (specify): <br />2. Analysis - Test series requested: t " A F <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />rsr I y -7 <br />3. Field Data - Preservation: t <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 ( } and explain below. <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES <br />QAC <br />) NO( ) If NO, explain: <br />Date <br />Page 9 of 9 <br />