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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal %2.q V.& <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />r. <br />Sample Loc./ID No. �` r `�-- Lab. No.(s) <br />Sample Date `' l Time <br />Collected By r '�' h e l <br />Field Custodian i f •.r f- ,� <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />vVLLG1 <br />Vll'.7IIC LCLfW�illlU4 <br />1. Sample Type: Air Water <br />2. Analysis — Test series requested: <br />Soil <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Other (specify): <br />3. Field Data —Preservation: <br />Z fl d A <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />b. 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 24 of 24 <br />