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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal - S 23,41 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Cation City, CO 81215 Caiion City, CO 81215 <br />Sample Loc./ID No. 4J Gc. ?? <br />Sample Date Time `` Sr <br />Collected By <br />'P <br />Field Custodian <br />Cotter Off-Site Destination <br />Delivered By 13? ff rl (I Y ZA _ 19 Field Data - Preservation: <br /> <br />Received By <br />Date Recd. , <br />Time Recd. c 10;0 <br />J ; <br />1. Sample Type: Air Water / Soil Other (specify): <br />7 <br />2. Analysis - Test series requested: /""? -PA f <br />3. <br />4. <br />5. <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />Lab. No.(s) <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <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 /> <br />Page 32 of 39