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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i ap S 25-410 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S(10 P/- Lab. No.(s) <br />Sample Date P ' 2 22 -Z 0/0 Time 13 :go Date Data Entered <br />Collected By B / N?c Inv/ Data Entry By <br />714- <br />Field Custodian >> <br />Laboratory Destination if not Cotter: <br />C 0 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br /> <br />N ? <br />1. Sample Type: Air Water I Soil Other (specify): <br />2. Analysis - Test series requested: re d'- <br />3. Field Data - Preservation: o,c 3-7 h? -7, 5n <br />r/s¢ ?; 1. ?.5v2 its r '` n S Li <br />-r S <br />4. Date analysis required by (if not Holding Time).. <br />5. Special handling conditions or other instructions: <br />6. Invalldating circumstances? If YES initial <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 />otter R--Site Desunation <br /> <br /> a <br /> <br />1160 <br />) and explain below, <br />Date <br />Page 16 of 20