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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal s S 23352 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Canon City, CO 81215 Canon City, CO 81215 <br />Sample Loc./ID No. Lab. No.(s) <br />Sample Date Time / N 5" <br />Collected By f ,? r `f/- <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />%AOLLVE V11-01LG 1/G3L1110L1UU <br />- <br />? 2 <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />c.• <br />Sample Type: Air Water Soil Other (specify): <br />Analysis - Test series requested: 61lr e". rv •? + ?' <br />3. Field Data -Preservation* 2. S <br />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 />) and explain below. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC <br />Date <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Page 18 of 20