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<br />W <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal L: sZHU <br />C: P.O. Box 1750 S: P.O Box 1750 N: P.O. Boa 700 <br />Callon City, CO 81215 Cafion City, CO 81215 Nncla, CO 81424 <br />Sample LocJID No. Lab. No.(s) <br />Sample Date Time Date Data Entered <br />Collected By. ?Date Entry By <br />Field Custodian A- 0 4i T-??....?.r Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Cotter OR• ite ea a on <br />.fry r <br /> o? <br /> <br />1'L'?csU . <br />1. Sample Type: Air Water -f- <br />2. Analysis - Test series requested: <br />/. / <br />3. Field Data -Preservation: lot, <br /> <br />??, (Oc.•? zf <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 />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC Date <br />{ ) Check If additional attachments. <br />QA Review: <br />m r <br />.., tr 4 to <br />Z 3 ? 3 .lr <br />Soil Other (specify): <br />Page 15 of 20