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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 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. 1 �+ �^ `� { j I Lab. No-(s) <br />Sample Date 6- Y ' Time / V 5 <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />I,QLLCC <br />vu'vaw aiw•.....r..... <br />roc <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />1b 0 <br />i <br />/ <br />r <br />6.1 <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: ��: r � G ^° r .0 �� <br />ell <br />3. Field Data - Preservation:��* < -'r ►� ' �" ''' ti" i D C 1 <br />00 (1-' <br />7 ,,... <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 />) NO( ) If NO, explain: <br />QAC Date <br />