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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 5 2 5 4 2 0 <br />C: P.Q. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81//21.5 // Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. SW t l-- Lab. No.(s) <br />Sample Date /V -2 O-2 O/ 6 Time / ?+ v Date Data Entered <br />Collected By Aql_ 7+ Data Entry By <br />Field Custodian y°-4 .• ?..- Laboratory Destination if not Cotter: <br />C tt not <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />U er -Site Destination <br /> <br /> <br /> <br />?e? <br />r? <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: ?? •=?a <br />3. Field Data -Preservation: 7"" 0 >7 71-1 r ?.?. S e ?,,.? -? d! ??? ?,, s r z. , / - O. 5 - FiQ /ya3 7 , S - <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 Date <br />Page 35 of 39