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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal :;2S 25191 <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. S W 130S Lab. No.(s) <br />Sample Date 9 ' f " l u / p Tie _ ! yy <br />Collected By Lj rO?...v e, <br />Field Custodian Q ?Oi"?? e ?? <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />,r J.P <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: (0" r a 1 <br />3. Field Data - Preservation: T o? 6. y <br />ri..i s e e') . d1,_/ S A <br />t? <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />6. Invalidating circumstances? BYES initial { ) and explain below. <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( <br />) It NO, explain: <br />QAC Date