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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal _ Hen <br />C: P.O. Boa 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cason City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. C✓ Lab. No.(s) <br />Sample Date 1. Time 10 �, J;} <br />Collected By _ <br />Field Custodian /=� $`- <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />Fp <br />%.%ro l <br />7-�'/ <br />Vll-alm In umuon <br />. <br />rY f <br />... ck$%, kLs <br />-u <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />a ,- <br />��4 „! r <br />Sample Type: Air Water r Soil <br />Analysis - Test series requested: 7r”" / r.' / <br />Other (specify): <br />3. Field bata - Preservation: f r f E sF f -J '` �. Y0 ` ' y .Z G <br />4. Date analysis required %*%a Holding Time): <br />5. Special handling conditions or other instructions: <br />Invalidating circumstances? If YES initial <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? <br />) and explain below. <br />YES( - ) NO( ) I[ NO, explain: <br />QAC Date <br />Page 25 of 25 <br />