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<br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />C: P:O: Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. <44/ ? 0 S Lab. No.(s) <br />Sample Dnte ? ' I ?'?O/? Thae S ??' <br />Collected By AKd ` ro..^•.v t; <br />Field Custodian -Ad Z -ree-- ? <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />I.OLICC Vll??7isc yws...w..v.. <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory. Destination if not Cotter: <br />A,. C- se i .c ?o t r_ 1G <br />43 S' : -f ?- ? G-k <br />2 CIO 2- <br />A? <br />?t.^ 00 <br />1. Sample Typed Air Water j Soil Other (specify): <br />2. Analysis - Test series requested: <br />3. <br />Field Data - <br />t.J <br />4. Date analysis required by (if not Holding Time): <br />S. 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 Reviews <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />Date <br />-- - -Page 37 of?9' --