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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal :12 S IS457 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Cafion City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. S' Gc/- v3 Lab. No.(s) <br />Sample Date -/9 - 2 0/ O Time.: Date Data Entered <br />Collected By c .. ?_ Data Entry By <br />Field Custodian Ll ~e' -- ` Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water Soil Other (specify): <br />ecu to / <br />2. Analysis - Test series requested: ?.r f A 3. Field Data - Preservation: 7 / ?- r? ?• a ^ J. 3 <br />r...C n (-,I ? J- A10 <br /> <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 <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 32 of 37