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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal %*-t <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Cation City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br /> Sample LocAD No._ ', (•<� /�(,�� Lab. No.(s) <br /> Sample Date a 1 > • r / Time a, , , -3 C? Date Data Entered <br /> Collected By '� .. „ �' _ Data Entry By <br /> Field Custodian Laboratory Destination if not Co�ter: <br /> Cotter Off-Site Destination �- ,, ; / <br /> Delivered By �a ;, �:=:.-,.,6. e� } ? i" .-� p •� �• ff r`'� � 'f <br /> Received By <br /> Date Recd. <br /> Time Recd. <br /> I. Sample Type: Air Water -L— Soil Other (specify): <br /> 2. Analysis- Test series requested: f6 <br /> 3. Field Data-Preservation: <br /> 21 <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 12 of 15 <br />