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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S 2 9 4 3 9 <br />C: P.O. Box 1750 <br />Cafion City, CO 81215 <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S W j% Lab. No.(s) <br />Sample Date / J % " / 4 Time VI'. . Uv <br />Collected By /? : S 7474 <br />Field Custodian o `'> % r' 0,7r. A 1. Laboratory Destination if not Cotter: <br />Date Data Entered <br />Data Entry By <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water S Soil Other (specify): <br />Off St.e D ti ti <br />l..V«Cf <br />- 1 es as VR <br />A,4 <br />Ck <br />NO/51 \5 <br />°1=55 <br />iT l� ✓ ) 11 IC; J V � .�. IC.' / 1 < <br />z3�3 S�. /f etper` <br />g26C/ <br />2. Analysis — • Test series requested: 1U n < < <br />I <br />3. Field Data — Preservation: T d� /5".. 41,3 H 7 /R (""....1 7 411 u S w/1. I <br />evil Sr << -',/ 3. E:) 4y'',9 1 -t i r , a, Z S L �-/! //4'6'? T�: 11 <br />/C lei" yO ./ } o, S'L 1 f4 (0., 1. s <br />5 - '?fes/ - Y. fly / 7 �.. " 1 <br />G <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 I ) If NO, explain: <br />QAC Date <br />Pag 1A of 10 <br />