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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S 2 5 3 83 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S (V `'L 14 ??- Lab. No.(s) <br />Sample Date / J-.Z 9 -1???f v Time 1 d ?r S ~ Date Data Entered <br />Collected By ,.? TyN? e, Data Entry By <br />Field Custodian <br />??, Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /> vu-Sue Lesunauon <br /> <br /> i rtJ !,? <br /> <br />G /U <br /> 17 <br /> <br /> <br /> <br /> <br /> <br />1. Sample Type: Air Water. -.Jo_ Soil Other (specify): <br />2. Analysis - Test series requested: "/0-' <br />3. Field Data - Preservation: , 99 o ? <br />Les /A <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 32 of 37