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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal N1° d-21419 <br />C. P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion City, CO 8121$ Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./1D No. -5 t(-? IS P..1-S Lab. No.(s) <br />Sample Date 11,' 2 2 `'Z J/`) Tune Date Data Entered <br />Collected By .6 f.P"? c _ Data Entry By <br />Field Custodian I.? r?f+/i ..? Laboratory Destination if not Cotter: <br />D <br />o <br />tter O <br />ff <br />-Site est Batt an <br />' <br />// <br />4h I?NNL• n <br />(}? <br />1 Nl??i !.h <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />a? <br />1. Sample Type: Air Water (tf Soil Other (specify): <br />2, Analysis - Test series requested: C" <br />3. Field Data - Preservation: <br />7A ? I U. S /. 1,F,4/1&d- Sa "L J a <br />2. .S ?..?. <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />4. Date analysis required by (if not Holding Time): _ <br />5. Special bandling 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( j It NO, explain: <br />QAC Date <br />) and explain below. <br />Page 15 of 20