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i <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S <br />C: P.O. Box 1750 S: P.O. Bog 1750 N: P.O. Box 700 <br />Cation City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. <br />Sample Date ,l • � ' / 4� Time <br />Collected By A <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />FA <br />3. <br />a.va&or <br />vu-01M Mmunsuun <br />— L <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination U not Cotter: <br />/ A !_fig <br />e'. <br />Sample 1lype: Air Water. 7 Soil Other (specify): <br />Analysis — Test series requested: , `• le / <br />Field Data — Preservation: <br />.s .4 / , <br />4. Date analysis required by (if not holding Time): <br />S. Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial ( ) and explain below. <br />COMMENTS — Explanation of noted items: <br />—a <br />( Check N additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: (1 <br />QAC Date <br />1 <br />r <br />0 <br />Page 26 of 26 <br />