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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S25180 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. Lab. No.(s) <br />Sample Date <br />Collected By TP No.? <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.uaaca vu-?uc arc?uuuaauu <br /> n <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />^/ <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: Tc- 4 /,r <br />3. Field Data - Preservation: 7 5 O (X s I ` <br />k ell :"7 "-f <br />l - U. S- L U/=A /f ,, D/? <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 40 of 44