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. F COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Cafion City, CO 81215 Cafion City, CO 81215 <br />Sample Loc./ID No.(''f� Lab. No. {s) <br />Sample Date _j_:[,D ` f.3 Time —La–L17— <br />Collected By t°•"� <br />Field Custodian <br />Delivered By d (� { z '► ^" "' I <br />Received By ej 7 <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />t tfl� r� = �.J' rS h <br />1 rte- l' JV <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis – Test series requested: <br />41 <br />4. <br />5. <br />Field Data – Preservation: <br />11 tiCA <br />L �- So S „l O _� <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 />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO <br />QAC <br />1--ti '7, cat 3 Cc-,-V V / t- <br />i6 At-4 03'2011 t- <br />bb s, <br />UrA Vv 014 -1-”: nd <br />) and explain below. <br />) If NO, explain: <br />Date <br />Page 26 of 26 <br />