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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S 2 5 2 6 3 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cadon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. A s ' b 0 /A Lab. No.(s) <br />Sample Date ' b - 2 °/ J Time _ ?- - -Date Data Entered <br />Collected By Data Entry By <br />Field Custodian / ?P...v Laboratory Destination if not Cotter: <br />Cotter Off Site Destination ' <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /> <br /> <br /> <br /> <br /> <br />1. Sample Type: Air Water -? Soil Other (specify): <br />2. Analysis - Test series requested: <br />3. Field Data - Preservation: 2, 0 5-(- <br />c <br />1 <br />l ? U t= / -? S -L G/?'=/I Nz 54P 4 J S /}/,- D iI <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: 4 7T c. ?Q <br />( X ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC Date <br />Page 21 of 21