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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal s 25250 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S a. s Lab. No.(s) <br />Sample Date /D 2 6 -24071me Date Data Entered <br />Collected By Data Entry By <br />Field Custodian 'q I-, ??y?/ Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water r Soil Other (specify): <br />2. Analysis - Test series requested: r ¢ f <br />r ? <br />3. Field Data - Preservath I f 0 <br />4. <br />5. <br /> <br />-Z. S 'CA- <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 />Page 31 of 32