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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 N: P.O. Box 700 <br />Capon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. _"�✓ Lab. No,(s) <br />Sample Date ' ':� -'• Time4 j <br />Collected By • '� ` ; r n t' r T <br />Field Custodian , <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />.,�.« <br />vii-anc ,pesunauon <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />' rt tr• F' � y �� c� - <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis— Test series requested: ^ f <br />3. <br />4. <br />5. <br />Field Data — Preservation: <br />( <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />b. 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( <br />QAC <br />) If NO, explain: <br />Date <br />Page 37 of 37 <br />