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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ::_ s 25122 <br />Q P.O. Box 1750 S: P.O. Box 1750 N: P.O. Boa 700 <br />Callon City, CO 31213 Cafion City, CO 81215 Nucla, CO 81424 <br />Sample Loe./ID No. ' ?J S Lab. No.(s) <br />Sample Date Time R y y <br />Collected By /!-1 .v <br />Field Custodian, Z <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.uuar vii-AMID Lzbu uun <br /> <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />1. Sample Type: Air Water I 1", Soil Other (specify): <br />2. Analysis - Test series requested: e 1-4. <br />3. Field Data - Preservation: ;r 7 <br />4. Date analysis required by (if not Holding Time): <br />S. 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