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<br />COTTER CORPORATION SAMPLE SUBMITTAL AND, TRACKING FORM <br />Sample Submittal S HIM <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion City, CO 81215 Cafion City, CO 81215 Nucia, CO 81424 <br />Sample LocJID No. _ ?.?? is <br />Sample Date 2 ' f? "a l/ Time /S / $ <br />Collected By 6v T,o....r?. <br />Field Custodian o? TD,..• c _- <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />3. <br />4. <br />5. <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter.: <br />fvw.p .5f .Z C- <br /> <br />Field Data - Preservation: <br />,W&- <br />Date analysis required by (if not Holding Time): <br />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 19 of 20 <br />Sample Type: Air Water Soil Other (specify): <br />Analysis - Test series requested:_ C, <br />?c+ ?.