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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal I!,, S 253$8 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S Cz-' A 4 D Lab. No.(s) <br />Sample Date 11-.0q-2010 Timse- 7 Date Data Entered <br />Collected By a 6.df? c ?/ i _ Data Entry By <br />Field Custodian _ /! Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: Air Water Soil) Other (specify): <br />2. Analysis -- Test series requested: [ <br />3. Field Data - Preservation: <br />r I-v f t' n, - J <br />(10ti <br />Z l <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 <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 />) and explain below. <br />Date <br />Page 39 of 40