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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ?; 2 Z 4 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Calton City, CO 81215 / Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. `?,, ? IT ?? Lab. No.(s) <br /> <br />Sample Date A:7 Time ?? S T V Date Data Entered <br />Collected By. 1 <? Data Entry B <br />_ Y <br />Field Custodian Laboratory Destination if not Cotter: <br />C tt <br />Delivered By. <br />Received By <br />Date Recd. <br />Time Recd. <br />o er Off-Site Destination// <br /> <br /> <br /> <br />(_ ? <br />![ C. <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: !cy c?K <br />3. Field Data -Preservation: /4 • ???_ 3 G, S ' t <br />r /N SAP r'-, ?,l 3. /S E 777- ` ?/Q3 ?? 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