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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 ,v Caiion City, CO 81215 <br />1; t E-11211 <br />Sample Loc./ID No. - <br />Lab. No.(s) <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Sample Date �_tir� -) 3 Time 10 V Date Data Entered <br />Collected By C^'�' (7 �'� rVy Data Entry By <br />Field Custodian U i d r {= ,-J Laboratory Destination if not Cotter: <br />Q� <br />et <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. r <br />Sample Type: Air Water Soil Other (specify): <br />Analysis - Test series requested: -1 G Ve 1 <br />1,.U6LCl <br />Vll�L7l1.0 YWWYYiIVY <br />-13 <br />�2 <br />.Wr GYA <br />1. <br />2. <br />3. <br />4. <br />5. <br />Field Data - Preservation: 4r- "` I tz "`� " °�W-"' —~"' <br />asE,.,.4-A k/. oyI <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 />