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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ;`: SUM <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Cation City, CO 812215 Cation City, CO 81215 <br />Sample LocJID No. — '+ 4<) /7 w f Lab. No.(s) _ <br />Sample Date 0 - P9 -12 Time 1030 ---- <br />Collected By ) 0 6 Te 4 n'6 �' <br />Field Custodian -A .,J ,Q4 el C ., <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />vu «ci <br />v[a -�uc Loauuauuu <br />cv <br />-- 0 <br />D <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 />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: P. Je / <br />3. Field Data - Preservation:: T °� 12-. 0 <br />rQ <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: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />Date <br />Page 7 of 8 <br />