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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal r ti A S 262 4 9 <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 LocJID No. f (-JA 0O? Lab. No.(s) <br />Sample Date 1,0?-+z410/J?e Date Data Entered <br />Collected By 1S ) w;"" Data Entry BY <br />Field Custodian /? ro.??v? -'? Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. at e <br />1. Sample Type: Air Water <br />??aa Soil Other (specify): <br />2. Analysis - Test series requested: ?-e? d1 <br />3. Field Data - Preservatio : T ,N, <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 />Date <br />Page 30 of 32