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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal N" S 21479 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. ..S W 14001 Lab. No.(s) <br />Sample Date //-2Z-20/-)'rime- U 10 Date Data Entered <br />Collected By -- Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Delivered By /` ??^-• ??7 ?? <br />Received By <br />Date'Recd. A. 9n "-f- <br />Time Recd. OA A-, 01 Ir <br />1. Sample Type: Air Water <br />Soil Other (specify): <br />2. Analysis - Test serjes requested: <br />3. Field Data - Preservation: T vy -3.1 V 7 ! 9 c p -3 3'6 <br />u S ?, c `y <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 />and explain below. <br />{ ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( } NO( <br />) If NO, explain: <br />Page 14 of 20