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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal % 047472 <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Cason City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. -} ✓ t <br /> p /� •._ Lab. No.(s) <br /> Sample Date )Y Time <br /> t-1 J Date Data Entered <br /> Collected By z,S r r' ^A< I f v Data Entry By <br /> Field Custodian 7n�0-4 Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By <br /> Received By �;,,, M. t'^s [ +r✓ �1/ 1 f <br /> Date Recd. <br /> Time Recd. 013 1i <br /> a +" <br /> 1. Sample Type: Air Water, 1 � Soil Other (specify): <br /> 2. Analysis— Test series requested: _ .,/,r <br /> 3. Field Data —Preservation: YJ ' �! + �• 1, z i� :�: ./ 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: <br /> ( ) Check if additional attachments. <br /> QA Review: <br /> Sample valid? YES ( ) NO ( ) If NO, explain: <br /> QAC Date <br /> Page 31 of 35 <br />