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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sa"e Sub�al S27436 <br /> Y V <br /> t <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 70U " <br /> Cason City, CO 81215 Cason City, CO 81215 Nucla, CO 81424 <br /> Sample LocJID No. 114 kI- Lab. No.(s) <br /> Sample Date `j' �' -' Y Time 1y. 10 Date Data Entered <br /> Collected By Data Entry By <br /> Field Custodian } y ' . < Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination ._ , ,; / c, <br /> Delivered By <br /> Received By <br /> Date Recd. <br /> Time Recd. <br /> 1. Sample Type: Air Water ` Soil Other (specify): <br /> 2. Analysis- Test series requested: r,-rA/r <br /> 3. Field Data-Preservation: _r eG F: fJH _, t/ r �� Cl r y s `C <br /> f <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 Date <br /> — Page 23 of 23 <br />