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COTTER CORPORATION SAMPLE SUBMITTAL AND:TRACKING FORM <br />Sample Submittal Ni S 15376 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO $1215 Nucla, CO 81424 <br />Sample Loc./ID No. S &I P/- Lab. No.(s) <br />Sample Date /V %Z 6 _Z0/ O Time S? Date Data Entered <br />Collected By _ Data Entry By <br />Field Custodian ?3 ivi4J Laboratory Destination if not Cotter: <br />Delivered By 1-4 V1, C 4b <br />Received By <br />Date Recd. , <br />Time Recd. <br />r? ) <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: _1-C A / <br />3. Field Data Preservation: 9, 1:0 Y /'? Iv ?/ Z L?nS ®4 S ` `~ <br />I Ao' t. _O N 7 v S r 7 cl ?- (r ?" /f? 0 CJ '? /1 <br />Qv 0// <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 eatplain below. <br />COMMENTS - Explanation of noted items: <br />i <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC <br />Date <br />Page 32 of 32 1