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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal _. S <br />C: P.O Box 1750 <br />S. P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. P, /T/ ', f Lab. No.(s) <br />Sample Date ` Time .7 ? Date Data Entered <br />Collected By Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Cotter Off -Site Destination <br />Delivered By <br />Received By <br />r <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water Soil <br />2. Analysis — Test series requested: <br />3. Field Data — Preservation: / <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 <br />COMMENTS — Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO <br />QAC <br />Other (specify): <br />r <br />) and explain below. <br />) If NO, explain: <br />Date <br />Page 16 of 17 <br />