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<br />COTTER CORPORATION SAMPLE SUBMITTAL AND. TRACKING FORM <br />Sample Submittal N S ss-04 <br /> <br />C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br />Ca$on City, CO 81215 Ca$on City, CO 81215 Nucla, CO 81424 <br />Sample Loc./W No. <br />Lab. No.(s) <br />Sample Date z -f l -Of/ Time 1 3 y4 <br />Collected By 4 ?? ?,P??C <br />Field Custodian z 4 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Co ter: <br />Pr K OiG ipI'?+PS ivC . <br />?3 <br /> <br />v - <br />1. Sample Type: Air Water Soil.---:-- Other (specify): <br />2. Analysis - Test series requested: l <br />3. Field Data - Preservation: <br /> <br />?V <br />J. <br />i4 <br />7 j <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 14 of 20