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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal 2 S 27475 _ <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Cation City, CO 81215 ,,rr Cation City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. �'�� �L«- Lab. No.(s) <br /> Sample Date &� - l 4 Time S p Date Data Entered <br /> Collected By > 7-1 G Data Entry By <br /> Field Custodian fa,a en G Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination .. n W S t, i <br /> Delivered By Z ZY ? <br /> Received By ,If= ��' V _�t.�•�. !.t/ +� , <br /> Date Reed. '5' - / `/ 'n <br /> Time Reed. cl <br /> 1. Sample Type: Air Water / Soil Other (specify): <br /> 2. Analysis- Test series requested: rJ e <br /> 3. Field Data- Preservation: <br /> / <br /> A U_t <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 34 of 35 <br />