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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 />Callon City, CO 81215 Ca»on;City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No.. .? r Lab. No.(s) <br />Sample Date 1/ - / poi J Time Q J Date Data Entered <br />Collected By Data Entry B <br />Field Custodian ... c% Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />?.Vaw1 V11-011e UVnIn8Llon <br /> <br />XV 22 - ?b <br />D'.1D <br />a S <br />1. Sample Type: Air Water Zr Soil Other (specify): <br />2. Analysis - Test series requested: (vr .p 2 <br />3. Field Data - Preservation: r a h 1.2 <br />6 ;1. ?_v??/ S !'/' (9 (' S C,/? <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 27 of 30 <br />