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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Cafion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. Lab. No.(s) <br />Sample Date /0' S D Time 3f7 Date Data Entered <br />Collected By d To Data Entry By <br />Field Custodian .13 ra `?-'F Laboratory Destination if not Cotter: <br />Delivered By <br />Received B <br />Date Recd. <br />Time Recd <br />?;oi[er v? -?,.? LGJNYPi3 <br />4 <br />c? <br />/0 <br />0'r z5 <br />?1. <br />1. Sample Type: Air Water Z??Sojl Other (specify): <br />2. Analysis - Test series requested: <br />O L. <br />3. Field Data - Preservation: 7 f 4? t! 7 ?s <br /> <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 <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 />) and explain below. <br />Date <br />Page 8 of 10