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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i ::. S 2 8 3 6 0 <br />C: P.O. Box 1750 <br />Caiion City, CO 81215 <br />Sample Loc./ID No. C (,t/ S <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion City, CO 81215 Nucla, CO 81424 <br />Lab. No.(s) <br />Sample Date 9 -2 ' / 5 Time ) • 50 Date Data Entered <br />Collected By 17: i T, -i „ c. 4 f <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />offs• <br />4l4Cl <br />V <br />- lte lk stlnatlon <br />r <br />16:35 <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />L 4 , y , <br />2! i S4 if 'r !.r /7.,- <br />r',-s��-,. - <br />'L C <br />-r <br />1. Sample Type: Air Water / �N Soil Other (specify): <br />2. Analysis — Test series requested: (7, I, / <br />3. Field Data — Preservation: 14./ 1g • 3 <br />O./1L i /////4ia7 2 <br />N 2 3o (7,,..; 4 /7Z ' k S ;, / z > `c <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 Date <br />Page 30 of 31 <br />