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COTTER CORPORATION SAMPLE SUBMITTAL AND. TRACKING FORM <br />Sample Submittal 11*2 S IRS13 <br />C: P.O. Box 1750. S: P.Q. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 Callon City, CO 81215 Nucle, CO 81424 <br />Sample LoeJID No. Lab. No.(s) <br />Sample Date Tlme j 3 -TO <br />Collected By Field Custodian o6o'?i?'??L---T M <br />Delivered By <br />Received By. <br />Date Reed. <br />Time Recd.. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />? s. ?.• . A/Y.?ZGUZ <br />S/ Vol <br />1. Sample Type: Air Water <br />2. Analysis - Test'series requested: <br />Soil. Other (specify):, <br />3. Field Data - Preservation: <br />V , <br />4. Date analysis required by (if not Holding Time): <br />S.- 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 13 of 20