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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 111112's 7 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. /0 t4l /'7 Lab. No.(s) <br />Sample Date y r y - % s _ Time 3 C7 <br />Collected By <br />Field Custodian IK'C' P 14 11 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />ri- <br />1 5 - <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not ,Cotter: <br />% PrCy LGbGni4 4" <br />f <br />ry r1/ .. <br />1,rs <br />1. Sample Type: Air Water N Soil Other (specify): <br />2. Analysis - Test series requested: 7a 4 %,e 9- <br />3. <br />3. Field Data - Preservation:: r �f. 3 ' // . 0.3 r+ rl S L) t � e- z ► C <br />Y!h J P 7-2 S .a rw ---174 r.JP <br />l6 v� _ � <br />� -21 ,.,. ' <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 <br />Date <br />Page 30 of 30 <br />