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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal f) S Z PJ g <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cason City, CO 8/1,215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. ! 1 ? ?3 Lab. No.(s) <br />Sample Date Date Data Entered <br />Collected By Data Entry By <br />Field Custodian ?/i? ?ra?• v Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />-L-U <br />?S? J•' .1 ... viiionc LGJ?lf14 NVY <br />r r- • z a `7 <br /> <br /> <br /> <br />1. Sample Type: Air Water <br />2. Analysis - Test series requested:1 <br /> <br />G? <br />Soil <br />Other (specify): <br />3. Field Data - Pre nation: nL d 1 h 7, 9/ 3 Y6 S ' s <br />//a. S o ev,,- se 4, yS ,,c z S 4 V -; s <br />4. Date analysis required by or 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 38 of 40