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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal :,1111 S25419 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Caiion City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. -!; ('4-1 /T.Pz '7 Lab. No.(s) <br />Sample Date Time /I ' / S~ Date Data Entered <br />Collected By Data Entry By <br />Field Custodian -" Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.v«u vii-JUe ues{IaauUu <br />,...+ r' +- may'!. crt. ! rv •?.• ! C <br /> <br /> <br /> <br /> <br />r ^' <br />1. Sample Type: Air Water. 7 Soil Other (specify): <br />2. Analysis - Test series requested: ?c ?c- <br />3. ]Field Data - Preservation: T 20 <br />r= .4IlAly 2 <?_ / Cry <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 />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />J <br />/Y1 S' i L' <br />Date <br />Page 34 of 39