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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal _ i,."7 S P-6244 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Bog 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. -? 1. # /- Lab. No.(s) <br />Sample Date ?? ' S =10 Time / ; 0'? <br />e-?-.-v <br />Collected By <br />Field Custodian ?. s ? ,, <br />Cotter Off-Site Destination <br />Delivered By N P t <br />Received <br />Date Rec a ? <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />J? <br />Time Recd. , t c ~ <br />1. Sample Type: Air Water ' Soil Other (specify): <br />2. Analysis - Test series requested: <br />3. Field Data - Preservation: row '9-/ 7. 9 0 (?,, ?- /7,,r) <br />C1 s ?e rn 0.04v/ 4C-1- r <br />4. <br />5. <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial ( ) and explain below. <br />COMMENTS - Explanation of noted items: <br />( ) Check N additional attachments. <br />QA Review: <br />Sample valid? YES <br />QAC <br />) NO ( ) If NO, explain: <br />Date <br />Page 10 of 10