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COTTER CORPORATION SAMPLE SUBMITTAL AND. TRACKING FORM <br />Sample Submittal ' ! S 2 5 19 <br />C: P.O. Box 1750 S' P.O. Box 1750 <br />Callon City, CO 81215 Cafion City, CO 81215 <br />Sample LocJID No. 0.5 "Lab. No.(s) _ -fw Sample Date 77" 16-2011 Time t- S Date Data Entered <br />Collected By Data Entry By <br />Field Custodian /x:3;6 .e-"..f"W4, .-+?.. Laboratory Destination if not Cotter: <br />C elp / f.. <br />7-- <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />otter Oft-Site Destination <br /> <br /> <br /> <br />1 7 <br />?- <br />r'.v. <br />Al Y, <br />',: !mot _?r"1 2 /t <br /> <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: <br />3. Field Data - Preservation: l ,?` "' ' t•. -L. <br />r 1 C' ? 3 <br />v .S.i S` <br />1z <br />4...:: Date analysis required by (if not Holding Time): <br />ti <br />5. Special handling conditions or other instructions: - v <br />6. Invalidating circumstances? If YES initial ' <br />$ ( and explain below. <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? VES ( ) NO ( ) If NO, explain: <br />QAC Date <br /> <br />N: P.O. Box 700. <br />Nucla, CO 82424 <br />