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COTTER CORPORATION SAMPLE SUBMITTAL AND. TRACKING FORM <br />Sample Submittal 112 S .2-5520 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cason City, CO 81215 Cason City, CO 81215 Nucla, CO 81424 <br />Sample. LocJID No. U f3 /0/ <br />Sample Date 2 o If Time [ 5 : S <br />Collect By AoA e <br />Field Custodian A0 <br />Delivered By <br />Received- By <br />Date Recd. <br />Time Recd. <br />a.u«cr a <br />aasusaauo <br />vu <br />ia? <br />w <br />sN .t r+. - <br />` <br />y <br />. <br />f ? C? ?Y <br /> <br /> <br />W V <br />Lab. No.(s) <br />Date.Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />e S jy E. <br /> <br />N <br />1. Sample Type: Air water soil Other (specify): <br />2. Analysis - Test series requested: <br />3. Field Data - Preservation: ate 2. S' /y 'I', S c/ • lz -S <br />77. / s ?'•~ <br />4. Date analysis required by (if not Holding Time): <br />S. Special handling conditions or other instructions: <br />6. Invalidating circumstances? "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 20 of 20 <br />