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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i - <br />'� S27906 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. w - Lab. No.(s) <br />Sample Date `�" / ` />� Time <br />Collected By JeACY2r� -1 . FieldCustodian jj e S <br />Delivered By <br />Received By <br />Date Recd. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />0 44 <z v.. lv. , <br />2353 <br />-S<2 /71 rr(.1 P <br />#t'-LyY. <br />Time Recd. I 10 .1S r <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: To /-e ;' <br />3. Field Data - Preservation: 7` <br />ywp1 1 �L • I" ����b ate. o�. q DG/ <br />P r c./ 5,11 1 t <br />4. Date analysis required by (if not Holding Time): <br />S. 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 20 of 21 <br />