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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal Ni°_ S 25587 <br />C: P.O. Box 1750 S: RO. Box 1750 N: P.O. Box 700 . <br />Cafion City, CO 81215 Cafion City, CO 81215. Nucla, CO 81424 <br />Sample LocJID No. a Lab. No.(s) <br />Sample Date 2 - ?f -70// Time `? ?y Date Data Entered <br />Collected By ?.? o Data Entry By <br />Field Custodian Laboratory Destination `if not Co r: <br />L .:a r <br />Delivered By <br />Received. By <br />Date Recd.. <br />Time Reed. <br />er <br />Co Off-Site Destination <br />rf <br />/ <br />b iA0--,&Af epo/ <br /> So 2A%.XQ.- <br /> <br /> <br />O ! - <br />4 t9 r ew <br />? <br />@#A.•? <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: o V, f <br />3. <br />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( ) If NO, explain: <br />QAC Date <br />Page 17 of 20