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<br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Y: <br />Sample Submittal' C: P.O. Box 1750 S: RO. Box 1750 N: P.O. Box 700 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. + A Lab. No.(s) <br />Sample Date S-16--2t,91 Time Date Data Entered <br />Collected By )4,-44 7.4g .r ti - Data Entry By <br />Field Custodian d g& 72-n-, -oa, Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Cotter ff-Ste DeBtmat on <br /> <br /> <br /> <br /> <br />+nr?'ICtr ?' o tart: a,iiC.4 Age C.. <br /> <br />1. Sample Type: Air Water Soil Other (specify): <br />2.. Analysis - Test series requested:. <br />3. Field Data - Preservation: !? - ;,,,, ! -... : <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( <br />) If NO, explain: <br />QAC Date <br />