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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal !: ,, S 25176 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucia, CO 81424 <br />Sample Loc./ID No. P, S O - IA Lab. No.(s) <br />Sample Date 929-.2,Y0 Time ('o <br />Collected By 1 v <br />i , ,... <br />Field Custodian J? <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />?.vuc¦ <br />jy Vu-pllC LCS?Iaa UOn <br /> v <br /> gam, <br /> 9•GD <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />N <br />1.11 <br />1 `' IT & <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: ra k° <br />r ? <br />3. Field Data -Preservation: , A S <br />4. <br />5. <br />Date analysis required by (if not Holding Time): _ <br />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 8 of 8