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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal t% S 2 5 6 5 d <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 Cation City, C0.81215 Nucla, CO 81424 <br />Sample Loc./ID No. _,4:7 (Al /I/- Lab. No.(s) <br />Sample Date Time •? <br />Collected By I' e,..??c .. <br />Date Data Entered <br />Data Entry By <br />Field Custodian d t) Lzz Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Cotter - ate es a on <br />'To <br />?' f y.y titi-C/? <br /> <br /> <br />CAz /r 0 / C. tJ,r / -2 ly <br />2 -7 6 <br /> <br />4 ` <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis- Test series requested: :7? rte <br />3. Field Data - Preservation: 7 O Le .S <br />??'sn? S .e c°t?•?? c. t.c„e...c' ?i z > L. 5~ ? //'Vo' <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 39 of 43 <br />