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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />C: P.O. Box 1750 S: <br />Canon City, CO 81215 <br />Sample Loc./ID No. cL/ <br />s28498 <br />P.O. Box 1750 <br />Caifon City, CO 81215 <br />Sample Date // - //- / S _ Time <br />Collected By 1-C- <br />//.do <br />r <br />Field Custodian Il 4 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1.VIICl <br />Vll'AIIC I/CDIII1 IUII <br />!(0 4 T <br />`, td ,, <br />kl <br />Z/ S <br />0.(5 <br />1. Sample Type: Air <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />2 5 3 Cc /11- C` <br />Water Soil <br />2. Analysis — Test series requested: 7 6/4 Z <br />, f 7 6 Cl / <br />Other (specify): <br />3. Field Data — PreservJatio�n/‘C-:� F `C. P ci. S ^ /�' 7, 00 ,�, / Z C 2 4' se_,, <br />j/ 5 ' <br />v/r S to N <br />f" <br />/.(.� �eJ2 , �ll /''/ 3 J <br />O 1) L F// f-1 A/01 Z r // , /6 U/- A lilt/ a, 'Z <br />D. G Lei/, //Z spy 7 G' <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />dp-`4. <br />6. Invalidating circumstances? If YES initial ( <br />) and explain below. <br />COMMENTS — Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( <br />) If NO, explain: <br />QAC <br />Date <br />Page 16 of 16 <br />