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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 112 s 25243 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Cafion City, CO 81215 Callon City, CO 81215 <br />Sample Loc./ID No. ? Lab. No.(s) _, <br />Sample Date Time 0 VO <br />Collected By ?,???-?' G <br />Field Custodian <br />Delivered By <br />Received <br />Date Rec . <br />Time Recd. <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination U not Cotter: <br />+44~!/ <br />1. Sample Type: Air Water ___L Soil Other (specify): <br />2. Analysis- Test series requested: rf e <br />3. Field Data - Preservation: / S7- / ??/ 12D <br />4. <br /> <br /> <br />o [? !D <br />Low <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />6. Invalidating circumstances? If YES initial ( ) and explain below. <br />COMMENTS - Explan ion nsteil items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />1-,1'44?7' ?, -,% <br />v. <br />Date <br />Page 9 of 10