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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i .' s 2 5 3 61 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Cation City, CO 81215 Canon City, CO 81215 <br />Sample Loc./ID No. -?? 4 of / Lab. No.(s) _ <br />Sample Date Time 2 ? 0 <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />?.ULMI v11-01M JVV3L]n41ivu <br />/ V15- <br /> <br />// <br />' <br />7 <br />7 ZF?- 1, A <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />i N <br />A a i . <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: S ! Ile' <br />3. Field Data - Preser/vvati1on j L t 6 ? ,J? c }, r / y ?? C•?"'?` <. t ` <br />OL- <br />60el- --1 1141 A/ <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: _ ? / r w <br />( r ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC <br /> <br />Date <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />. Page 30 of 31