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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />' <br />Sample Submittal _ ? '' ._ s25274 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Canon City, CO 81215 Canon City, CO 81215 <br />Sample Loc./ID No. .5ffwl' o Lab. No.(s) <br />Sample Date /e20/,?-)Time 12.20 <br />Collected By A•'-i e ' <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />< <br />ouCr VIIValtc Lcauwaawu <br />(JJ <br />/y <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />4 <br />Ej <br />G%~ <br />,N <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: ea cam' '@ <br />3. Field Data - Preservation: 7 3 o <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />b. Invalidating circumstances? If YES initial ( } and explain below. <br />COMMENTS - Explanation of noted items: <br />( ) 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 36 of 36