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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal N," S MS 5 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Cafion City, CO 81215 Cafion City, CO 81215 <br />Sample Loc./ID No. .S 6? I? 0 j.S Lab. No.(s) <br />Sample Date ' / 9 " .2 OHO Time /2:00 <br />Collected By <br />Field Custodian ?.S' Tp.,..•. f ?^ <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />c' <br />1. Sample Type: Air Water / Soil Other (specify): <br />2. Analysis - Test series requested: S' A (n ?'e <br />3. Field Data - Preservation: ?u S+ ^"? 3 S? cA <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 /> VULLCC V1L'J?K L?A?fY?a?vu <br /> <br /> <br /> <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Page 30 of 37