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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal NIII"' G A <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. 4 d o Lab. No.(s) <br /> Sample Date jr -;, Thee } �.S� Date Data Entered <br /> Collected By rT <br /> Data Entry By <br /> Field Custodian Laboratory Destination if not Cotter: <br /> Cotter i Off-Site Destination ,.. <br /> Delivered By 1�^.,ir<: �:.�f y -7 ? '� <br /> Received B <br /> Date Recd. <br /> Time Recd. <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis — Test series requested: (1� -✓ a <br /> 3. Field Data—Preservation: Pr /d . 1.0 <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 8 of 15 <br />