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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ' <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 (/<-) 0 -S Lab. No.(s) <br />Sample Date l' -;,,7- 2oI 1 Time Date Data Entered <br />Collected By Data Entry By <br />Field Custodian W 7r,0? r•?'C Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />.." %;R vii-a[le uebtinauon <br />CA, um'&4 Qd Pv, <br />, <br /> <br /> <br />v <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: : o <br />ti.. <br />3. Field Data - Preservation: <br />?_ 7 h <br />yt <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 33 of 37