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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ?N'Z I S25271 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Caiion City, CO 81215 Callon City, CO 81215 Nncla, CO 81424 <br />Sample Loc./ID No. SC4/ I? Lab. No.(s) <br />Sample Date /0 -19-ZQIO Time 15- <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.vuca <br />.4116- Vll-Al1C UesllazlllOII <br /> 0 <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br />1. Sample Type: Air Water 1 Soil Other (specify): <br />2. Analysis - Test series requested: C.-o t <br />3. <br />Field Data - Preservation: <br />I <br />4. Date analysis required by (if not Holding Time): <br />S. Special handling conditions or other instructions: <br />I <br />6. 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 />Page 26 of 29