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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 />Caflon City, CO 81215 Canon Ouy, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. 5 {-? f Lab. No.(s) <br />Sample Date `/a Time O t <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />?,.U L1C1 Vli-OIIC IJ GJ ll11ll LIV f1 <br /> <br /> X <br /> r <br />?t <br />-Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br /> <br /> <br /> <br /> r <br /> <br />?! - is <br />1. Sample Type: Air Water??_ Soil Other (specify): <br />2. Analysis - Test series requested: I G ? /-'r <br />3. Field Data - Preservation: r S S 7 ?? CJ_ 5 0 f <br />1 <br />!7 <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 - Date ___ <br />Page 38- Of -9