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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />'Z. S25677 <br />Sample Submittal 1? ,. <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 Loc./ID No. Lab. No.(s). <br />Sample Date u .• 'r?` Time Date Data Entered <br />Collected By 0E ?v Data Entry By <br />Field Custodian A24 A /a ov Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />Cotter O -rte efs ma Boa <br />1? P <br /> <br />1 ? <br /> <br />. 41 0.,. <br />Sample Type: Air Water Soil Other (specify): <br />Analysis - Test series requested: (4 <br />3. Field Data - Preservat'on:? <br />;2 s <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 <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br /> <br />QAC <br />Date <br /> <br />and explain below.: <br />