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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal N-0 S IS241_ <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. sewA 6'e-ID Lab. No.(s) <br />Sample Date U Time Date Data Entered <br />Collected By Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Cotter Of -Site Destination <br />v <br />Delivered By 4 <br />Received B , <br />Date Recd. 10(0/0 <br />i <br />Time Recd. 0'y 25 44, <br />.r <br />1. Sample Type: Air Water ?JSoil Other (specify): <br />2. Analysis - Test series requested: <br />06. <br />3. Field Data - Preservation: /d• <br />`, 1. <br />yr ,? r Q r .y . t/, vg' i.4 J e/ , S <br />..u <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 <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( } NO ( ) If NO, explain: <br />QAC <br />) and explain below. <br />Date <br />Page 8 of 10