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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal :11.2 S r4 <br />C: P.O. Boa 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 LocJID No. -5 W/f "_% /2 Lab. No.(s) <br />Sample Date j " �' Time. �L3 <br />Collected By X7;, % "' • fi,.•t <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.vsaar <br />vu -aua uesumuun <br />L� <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination it not Cotter: <br />1. Sample Type: Air Water �_ Soil Other (specify): <br />2. Analysis — Test series requested: lei .4 A- <br />3. Field Data — Preservation: T e 1 S. 0 , ?/v 7. / ry <f ? 2 `I ' ''e- <br />... � t - I , y - ;'� ; � r , . -- fl ,ter • f? ,�, ,,,. <br />_ � '• l.�t /% •/` /rl/ f 3 __ 2 ,4•. - � i (_ : / t' j L '�''` // i ;' � SU 4 � ... � � -. <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 ( ) WNO, explain: -` <br />QAC D4 -� <br />C1 <br />Page 24 of 24 <br />