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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />v Sample Submittal �� _ <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. `� f��/ f ' �' Lab. No.(s) <br />Sample Date `J /i `r Time IL I <br />Collected By _ ` i - r ry r 11 y <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />3. <br />a.vawr <br />vii -.��� uc�ana�iun <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Vii- r.t <br />Sample Type: Air Water Soil <br />Analysis - Test series requested: <br />Other (specify): <br />Field Data - Preservation: 4 r °r <br />4. Date analysis required by (if not Holding Time): <br />S. Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES <br />QAC <br />W <br />) and explain below. <br />) NO( ) If NO, explain: <br />Date <br />Page 36 of 37 <br />