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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal t?° s29390 <br />C. P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S 6"? /'L- Lab. No.(s) <br />Sample Date 11 Time ?L Date Data Entered _ <br />Collected By Data Entry By <br />Field Custodian ?Z r".• < Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />VyLtGL <br /> <br />rs rP??,? VIVO t6 livatluatlvu <br />7 <br />-fly <br /> <br /> Ml I <br /> <br />1 tr 4P ' <br />O~ U <br />1. Sample Type: Air Water r/ Soil Other (specify): <br />2. Analysis - Test series requested: ?v cz r <br />c.. <br />3. Field Data -Preservation: '7 7 • v ., 3 ?/ L 1 <- ' s <br />p/vin rr?..G/ 7.? (it) °` o• Z i/4iyf/d? --?- <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 37 of 40