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<br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal N-0 R 95.67- <br />C: P.O. Box 1750 S: P.O. Boa 1950 <br />Cason City, CO' 81215 Cason City, CO 81215 <br />Sample LocJID No. <br />Sample Date. 2 ' /.s, Time 4 <br />Collected By <br />Field Custodian _ <br />Delivered BY. <br />Received. By <br />Date Recd. <br />Time Recd. <br />Lab. No.(s) <br />N: P.O. Box 700 <br />- Nucle, CO 81424 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />L 41 a, ? fem.: r e s arc. <br />e've <br />AW .07 -7 <br />N <br />1. Sample Type Air Water Soil Other (specify): <br />2. Analysis - Test series requested. t <br />„ <br />3. Field Data - Preservation: <br />Cam.. Z. 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 />-- - -- - - ---3 of 3g-