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� � Y <br />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 />Canon City, CO 81215 Callon City, CO 81215 Nucia, CO 81424 <br />Sample Loc. /ID No. w — U f L Lab. No.(s) <br />Sample Date Time <br />Collected By <br />Field Custodian l` r `-' r� �► c. --► <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />�.va�ci <br />b a , <br />Vll -�71[e Le6LIII8Z10II <br />l r f',• s' <br />r` <br />(l. J / <br />JAZZ JILo <br />e <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />t <br />t: <br />J <br />1. Sample Type: Air Watery Soil Other (specify): <br />2. Analysis — Test series requested: t.- - r�C' <br />0 <br />4. <br />5. <br />Date analysis required by (if not Holding Time): _ <br />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 <br />QAC <br />) NO ( ) If NO, explain: <br />Date <br />Page 29 of 29 <br />