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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i`,;- S27063 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Caiion City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. _ !"� /.I VP A � �/ Lab. No.(s) <br />Sample Date a - 2 - ()f L Time ') .' 4 <br />Collected By Bo 4- <br />Field Custodian s, �, Tf-,,, -.I _ "t <br />Cotter i Off -Site Destination <br />Delivered By ZJ4 7,e% <br />Received By A" <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />tali <br />Date Recd. ` <br />Time Recd. i <br />1. Sample Type: Air Water `7 Soil Other (specify): <br />2. Analysis- Test series requested: S _Sou /" / �. r< f r,, ,/ rP ,, (7, r ' <br />3. Field Data - Preservation: 7o6 N ef, <br />i <br />4. Date 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: 1 ro =e �. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC Date <br />Page 12 of 12 <br />