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C: <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACM0440M <br />Sample Submittal <br />P.O. Box 1750 S: RO. Bw 1750 N-., to. jkw. 70. <br />Cafts City, CO 81215 Callon City, CO 91215 Nwh4 Cook" <br />Sample LocJID No. & 4/-/.3 <br />s,,pa pk -13Thee - Dow <br />C4&wtwBy <br />Time at". <br />%,US4ww <br />%MILIOAM lFcwtv"Uun <br />q0 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destiestion U not Cotter: <br />C- 0 i-,weLez <br />top& V'k <br />'C 4p- 11 <br />Other (1119"11�w <br />Air Water Sou Other <br />2. Aa*vb - 1104 series req0ft"z--f4* le <br />U1 <br />'r4quired by (if not Holding Time): <br />S. gowlat haadling conditions or other Instructions: <br />5. Is idatisg circumstances? If YES initial and eiplain below. <br />80$60eflen of noted items: <br />40. <br />Check If additional attachil.` <br />QA %*rUw: <br />'rllm? YES NO if NO, ex~. <br />QAC Date <br />Page 24 of 24 <br />