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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal Z12 1325655 <br />C: P.O. Box 1750 S: P.O. Box 1150. N: P.O. Box 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. _) S Lab. No.(s) <br />Sample Date Time o y <br />Collected By 1S .? ??,L. ,? a -?. <br />Field Custodian go 4. <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />l.L6L6a V11'01W LOMLIBULLUR <br /> <br />r• <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />£-" 0-S W L4o4 ar 4 tov /GC -_Ac <br />P/ <br />iGlt N <br />1. Sample Type: Air Water? Soil Other (specify): <br />2. Analysis - Test series requested: / i_l?1 rJ'Q <br />3. Field Data - Preservation: y. ?{ ?. 2 6 ... U S_U z 5 <br />rte. r c? r??, '122 yak ;Z, S <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 Date <br />Page 40 of 43 <br />