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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ;' S25271 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />CaiEon City, CO 81215 Calton City, CO 81215 <br />Sample Loc./ID No. - 5'6t/ A 0 01 Lab. No.(s) _ <br />Sample Date l U -1 3 -2 aftme -220 <br />Collected By L..vr/r <br />Field Custodian <br />Delivered By <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Received By <br />Date Recd. <br />Time Recd. c 1W t? S <br />1. Sample Type: Air Water rSoil Other (specify): <br />2. Analysis - Test series requested: / ", ? /0 z <br />Jy ,y 4 C <br />J•'` :" SCI / <br />r. t <br />3. Field Data - Preservation: 1 70 <br />Cv- <br />L Ale-, 0 ^-J7 <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: <br />( x ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO { ) If NO, explain: <br />QAC Date <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Page 33 of 36