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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal '--110 S 1101A <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. Ar ZAI - l <br />Sample Date 5 �" r' /JTime <br />Collected ByG'� <br />Field Custodian A i► <br />Cotter Off -Site Destination <br />Delivered By I./ . <br />Received By �k <br />Date Recd. 1 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />A P- M e .4 U /- c /,I J --' S 7 .1 G. <br />Time Recd. -f 7.3 U <br />1. Sample Type: Air Water � " Soil Other (specify): <br />2. Analysis - Test series requested: _ 11-L 4 14, 2- <br />3. Field Data - Preservation: <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 { <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 <br />Date <br />Page 24 of 24 <br />