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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal IL S25382 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S6-JA if Al Lab. No.(s) <br />Sample Date Z2-iv- R?0/6rime J•t57 <br />Collected By _f-" <br />Field Custodian l r r n. n/ s f <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />??«<¦ vu-oue Uesunanon <br /> <br /> <br /> <br />1. Sample Type: Air Water <br />2. Analysis- Test series requested: <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />6-, <br />Soil Other (specify): <br />bL <br />3. Field Data - Preservation: _ s7 o , 9// <br />?f, <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 31 of 37