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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal ._` S 42 <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Callon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. r Lab. No.(s) <br /> Sample Date 1 2I ' Time Date Data Entered <br /> r � <br /> Collected By '-'J- Data Entry By <br /> Field Custodian - 7: l 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 requested: �� j e' <br /> 3. Field Data—Preservation: ! `� %y / J z L*7 - <br /> 4. Date analysis required by (if not Holding Time): <br /> 5. Special handling conditions or other instructions: <br /> b. 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 7 of 8 <br />