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~ COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 1.10 _ S 25477 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.U. Box 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. _ _S tj A V /> Lab. No.(s) <br />Sample Date //- Z Z ?0/0 Time 00 Date Data Entered <br />Collected By Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />C tt 0 LIZ <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />o er _ff- te Des49112LIGU <br /> <br /> <br />O <br /> <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requetted: ? ' <br />3. Field Data - Preservation: r " <br />/'t S c f r?.. sf / N C (? ti l? S ?iQ??/tf O 7 S ?,+t J7 <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 jr additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( } If NO, explain: <br />QAC <br />Date <br />Page 13 of 20