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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal , S 27" <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 8,1-2115 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. m W - r Ff Lab. No.(s) <br />Sample Date & f 3 Time <br />Collected By /.�f Ire ^ f " r <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />♦.vaaar <br />vu -oiaa uasuunuvu <br />JJ <br />3 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination If not Cotter: <br />'� #,^ t.i <br />- <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: LI. Al <br />-f �� T <br />3. Field Data _Preservation. • ( r� •' 7 S y 'o!j' <br />L / Y Ls' � % � f:' /�%�%V ii' �i i..J,.+w, r f✓ fib � �,.. �/ l�`,�%%� ..%� �y, : %'c <br />Or <br />4. Date analysis required by (if not Holding Time): . <br />S. 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 ( } NO ( ) If NO, explain: <br />QAC Date <br />Page 23 of 23 <br />