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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal III! M472 <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> CaOon City, CO 81215 Caflon City, CO $1215 Nucla, CO 81424 <br /> Sample Loc./ID No. ' �r Lab. No.(s) <br /> Sample Date Time -' Date Data Entered <br /> Collected By %r. n. , ,. Data Entry By <br /> Field Custodian . ' r" t. __ """" Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By <br /> Received By //. .. <br /> Date Recd. <br /> Time Recd. ,1 <br /> 1. Sample Type: Air Water ? Soll Other(specify): <br /> 2. Analysis- Test series requested: <br /> 3. Field Data-Preservation: l '�"' �• `' < c_" '�`� <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 32 of 35 <br />