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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> •'+ A2 <br /> Sample Submittal -- <br /> } t N: P.O. BOX400 <br /> S: P CO51215 0,Box 1750 Nucla, CO 81424 <br /> C; P.O.Box 1750 - <br /> Cafion City, CO 81215" Cafion City, <br /> Lab.NoAs) <br /> Sample LocjID No. f <br /> S l' <br /> lime <br /> 3 : t Date Data Entered <br /> Sample Date <br /> t. Data Entry By <br /> Collected By <br /> Laboratory Destination if not Cotter: <br /> Field Custodian <br /> Cotter Off-Site Destination <br /> Delivered By 1 <br /> Received By <br /> Date Reed. C � <br /> Time Recd. � � ;r � " " <br /> 1. Sample Type: Air <br /> Water � Soil Other (specify): <br /> 2. Analysis — Test series requested: <br /> d Data—Preservation: � <br /> 3. Field f Al" <br /> 4. Date analysis required by (if not Holding Time): <br /> 5, Special handling conditions or other instructions: <br /> lain below.ex <br /> 6. Invalidating circumstances? If YES initial { ) and p <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 8 <br />