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COTTSI `CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />-. <br />Sample Submittal 12s 26872 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S w- X A H Lab. No.(s) <br />Sample Date ' �I 'fie 13 <br />Collected By a,1 %t'O't <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />l.uctul- <br />vu -aaac iicawuouvu <br />q S� <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />23 93 51 + C.- " fc t-1 h/ <br />64AfP01-, W r 62-601 <br />1. Sample Type: Air Water.. — Soil Other (specify): <br />2. Analysis - Test series requested: � u �7f'e <br />3. <br />4. <br />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 26 of 26 <br />