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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal N! S21244 <br />C: Y.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nueln, CO 81424 <br />Sample Loc./ID No. S (4/ /.3. '0L" Lab. No.(s) <br />Sample Date Time 0 y Date Data Entered <br />Collected By - ?"77-' Data Entry By <br />Field Custodian , ,7 ?'?-?? ?1%7? Laboratory Destination if not Cotter: <br />Cotter Off-Site Destination <br />Delivered By ?L NQr ?j <br />Received <br />Date Rec a <br />J? <br />Time Recd, f G ' <br />1. Sample Type: Air Water t Soil Other (specify): <br />2. Analysis - Test series requested: rd j <br />3. Field Data - Preservation: f oc- 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 ( ) 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 <br />Date <br />Page 10 of 10