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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 1-2 S2 5 657 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S14/6-9 <br />Sample Date Time 1 `?Z <br />Collected By y?? ????.? C .v' <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />IiV LLCI Vll'OlLC UC.IN <br />LSLIVII <br /> [ <br /> <br /> <br /> <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotterz <br /> <br /> <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: r_:+r <br />3. Field Data - <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 <br />QAC <br />Date <br />Page 42 of 43 <br />NO. ( ) If NO, explain: <br /> <br />