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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i .* -) S 255 4 6 8 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. SW f'?4 S Lab. No.(s) <br />Sample Date Mme I /o Date Data Entered <br />Collected By ?Pivr?c . Data Entry By <br />Field Custodian 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 />2. Analysis'- Test series requested: S' t A ?+ ?Aa <br />3. Field Data - Preservation: T /S. X •j // 7, y <br />-0.S <br />4. <br />5. <br /> <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 33 of 37