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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i ?? S 25 4 ?0 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. SS Cc/ A 0'% Lab. No.(s) <br />Sample Date >nme f <br />Collected By ?o....? . <br />Field Custodian l?o?..,v r <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />W fi <br />41 <br />1. Sample Type: Air Water f Soil Other (specify): <br />2. Analysis - lest series requested: r' <br />3. Field Data - Preservation: T e 14 .9 ?J y 7 75 (- 9 <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 <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES <br />) NO ( ) If NO, explain: <br />QAC Date <br />) and explain below. <br />Page 32 of 36