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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 3' S� <br />C: P.O. Box 1750 V S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Caiioa City, CO 81215 Nucla, CO 83424 <br />Sample Loc./ID No. --�' <br />r {'?t.. <br />Sample Date 2 %' ' 7 Time t -f'�' <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />LU�aC[ <br />vaa�oaac arcauuo«vu <br />— -z r <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />1 <br />r 44 <br />i.e <br />1. Sample Type: 4r Water Soil Other (specify): <br />2. Analysis — Test series requested: <br />U <br />El P <br />Field Data — Preservation: <br />�M <br />X <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 N additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( . - ) If NO, explain: -' <br />QAC ate of ~ <br />O <br />