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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />'l S25351 <br />Sample Submittal *?._ <br />C: P.O. Box 1750 S: <br />Canon City, CO 81215 <br />Sample Loc./ID No. S f Z .1? <br />P.O. Box 1750 <br />Canon City, CO 81215 <br />Lab. No.(s) <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Sample Date Time Date Data Entered <br />Collected By T?'?- •- Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />LVNCI Vll'O1L61/GJUn4LLVn <br /> <br />G <br />8 <br />.? o? .T0, <br /> <br />?r <br />1. Sample Type: Air Water 1 Soil Other (specify): <br />2. Analysis - Test series requested: Ur4 n/ i u'-. " /-y ? ) <br />7 ! <br />3. Field Data - Preservation: % /79 4. <br />5. <br />Date analysis required by (if not Holding Time): _ <br />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 13 of 20