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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ,042 SIT"1 <br />C: P.O. Boa 1750 S: P.O. Box 1750 N: P.O. Boa 700 <br />Cation City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. /07 W - / S Lab. No.(s) <br />Sample Date') ' � / Time <br />Collected By <br />1 <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />�.V&Lir <br />Vu -oak "a Uanuvn <br />,- <br />9-- - r <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />1. Sample Type: Air Water./ Soil Other (specify): <br />2. Analysis - Test series requested: L iv <br />3. Field Data - Preservation: f e � l 2. y <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 25 of 25 <br />