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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal _: S 2% 0 a 1 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />CaOon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />O <br />Sample Loc. /ID No. /11"'1 P �F ;� Lab. No.(s) <br />n <br />Sample Date -2 03 Time f % <br />Collected By Z06 .ry C <br />Field Custodian <br />Cotter Off -Site Destination <br />Delivered By 40(' 1p,. ri 6.4 <br />Received By <br />Date Recd. lot <br />Time Recd. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />`ter Al" <br />• -•— <br />(- y, < <br />1. Sample Type: Air Water . Y Soil Other (specify): <br />2. Analysis - Test series requested: T z , S lid( nc /` ,c J f� % re- r 4 <br />3. Field Data - Preservation: r Cc / '� . -z Z- <br />(j N i '" D !a r G P <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 />) and explain below. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC <br />Date <br />Page 12 of 12 <br />