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4 <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 1'," S 2 6 9 9 7 <br />C: P.O. Box 1750 <br />Caflon City, CO 81215 <br />Sample Loc./ID No. V 6 <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Sample Date 5 Z ' �S Time y� <br />Collected By��J��' t' ' <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />\.VtLrY <br />via -oi�c apcaumas'avu <br />!= � r- <br />, <br />477 <br />9.3v <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />_�` �,,. Z r r r <br />Time Recd. G ,� c ' <br />�, <br />Sample Type: Air Water Soil Other (specify): <br />Analysis — Test series requested: -r.- '(j /0 <br />1. <br />2. <br />3. <br />4. <br />5. <br />Field Data — Preservation: <br />O 1 —, <br />Date analysis required by (if not Holding Time): <br />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 />) and explain below. <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC Date <br />