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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 5 2 5 4 2 2 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215^ Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S (Cfo 6V,, ' Lab. No.(s) <br />Sample Date 10-22-2(210 Tai e. to 1S <br />-7' . <br />Collected By I- ' e. c <br />Field Custodian e <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.v?rci "'A"'ORC L'U."Ad UUn <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />e <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: <br />3. Field Data - Preservation: GO r e <br />4. <br />5. <br />Date analysis required by (if not Holding Time): <br />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 />Date <br /> <br />Page 37 of 39