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t <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ; s279171 - <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Boz 700 <br />CaOon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br />Sample Loc -RD No. l*w e 9, r• // _ Lab. No.(s) <br />Sample Date _i"�` 1) - -Time —� <br />Collected Bydb <br />Field Custodian r0d G A <br />Delivered By <br />Received By <br />Date Recd. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />3cil Sylt act,/( <br />"Z 6d/ <br />Time Recd. I dC <br />1. <br />2. <br />Sample Type: Air Water y Soil Other (specify): <br />Analysis — Test series requested: rA �r <br />3. Field Data —Preservation: / °t- 5 ("" ;Z 41 - <br />!� t 2�5•LEb f r�''Il ) -ger••,. n.ia. 19y S'rJ..•.. <br />n <br />/l_ FhH .Vd 7 d.. d 7 1 G 2 014 r 01S"1- !/rte'/ <br />TQe a 2fNHAA), -t 44 <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 />D <br />Page 13 of 13 <br />