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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal U) S25453 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S (dJ 1J ?? Lab. No.(s) <br />Sample Date S j'?-20/0-Time T 5-0 <br />Collected By 19 / 1'"10-+ C,- <br />Field Custodian )3 cell-I0 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />#,{ <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: S r? z /Q <br />3. Field Data - Preservation: /? n j <br />r . A / .? ' t( 0 o r-.-Y 1 L <br />P/ M j G .!' ti 5 to S / <br />r l <br />?7 <br />4. <br />5. <br />Z- 4,r A Al-4 /Z 2 - S' <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 36 of 37