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I <br /> COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal l.2 S= __ <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> CaOon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br /> Sample LocJID No. /` " L Lab. No.(s) <br /> Sample Date - 4 Time 00 Date Data Entered <br /> Collected By i 1. Data Entry By <br /> Field Custodian jI j6' T'e4� '� Laboratory Destination if not Cotter: <br /> Cotter Off.Site Destination <br /> Delivered By <br /> Received By <br /> Date Reed. <br /> Time Reed. <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis— Test series requestjed: _11�4 �f r <br /> 3. Field Data—Preservation: }L `f• pl // 7. is11 <br /> p�� <br /> 1) f t"f ! <br /> / i'FAi�/t/J .� a /L !� /`° l/I",�1 •JIt�� cr.. �' Z <br /> 4. Date analysis required by (if not Holding Time): <br /> 5. Special handling conditions oi other instructions: <br /> 6. Invalidating circumfitances? If YES initial ( ) and explain below. <br /> COMMENTS—Explanation of noted items: <br /> ( ) Check if additional attachments. <br /> 'i <br /> QA Review: _ <br /> Sample valid? YES ( ) NO ( ) If NO, explain: <br /> QAC Date <br /> j <br /> Page_28 Qf 29 <br />