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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal �`„ S2744 <br />4 <br />C: P.O. Box 1750 <br />CaSen City, CO 81�2�1,5% j <br />Sample Loc./ID No. <br />S: P.O. Bose 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 01424 <br />Sample Date F _ Thne 1.24' t 5'" <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By/ <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />I.VLLCC <br />V1Y�71li YG�V�Hit7lNVH <br />Sample Type: Air Water Soil <br />Analysis — Test series requested- <br />Lab. No. (s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Co er: <br />S <br />Other (specify): <br />3. Flel# Data — servation: 1 "P ` 7 t" " I <br />4. Dite 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 H additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO { ) If NO, explain: <br />QAC Date <br />Page 23 of 23 <br />