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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ::2 S25179 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Caiion City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S? 13 ar s Lab. No.(s) <br />Sample Date (V".2 q- Time <br />Collected By L? ?r <br />Field Custodian /? ?.. <br />Delivered By <br />Received By <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Date Recd. 4 <br />Time Recd. <br />1. <br />2. <br />J <br />Sample Type: Air Water Soil Other (specify): <br />Analysis - Test series requested: rG / Ic Yff,, A. c ,Scc i rc <br />3. Field Data - Preservation: ) S 3 ? 7 ?. 3 Z 3 <br />r l y, (2 <br />l 0. S L Z11// 7/1 i!/ r, 01. H 2. <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 Date <br />Page 39 of 44