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COTTER CORPORATION SAMPLE SUBMITTAL ANDITRACKING FORM <br />r <br />Sample Submittal 12 S 25435 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion City, CO 81215 / Callon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID o./?/ y ?e 1 I // Lab. No.(s) <br />Lt/[ L* <br />Sample Date Time, Date Data Entered <br />l <br />Collected By 1?(?. ??/E? Data Entry By <br />Field Custodian fem. Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />=- l <br /> <br /> <br />O ?c,v fv <br /> <br /> <br /> <br /> <br />1. Sample Type: Air Water s Soil Other (specify): <br />_'e <br />2. Analysis - Test series requested: - n ' <br />3. Field Data - Preservation: <br />4. <br />5. <br />l 61 OF /L G/ f ?9 /?,L CJ y S ..-t?? <br />Date analysis required by (if not Holding Time): <br />Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial ( ) and explain below. <br />COMMENTS - Explanation of noted items: <br />( X ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC Date <br />Page 22 of 22