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w <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Cation City, CO 81215 Callon City, CO 81215 <br />Sample. Loc./ID Noy ' <br />Sample Date 1/y"g`j-,20-11 Time /0'7041 <br />Collected By do <br />Field Custodians <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.va?ca VJJIAJLC JJCliLJa nglu 1 <br /> <br /> <br /> <br /> <br />Lab. No.(s) _ <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />-7 1 4e <br />?1. Sample Type: Air Water` Soil Other (specify): <br /> <br />2. Analysis - Test series requested: s:.a <br />3. Field Data - Preservation: <br />r <br />l <br />5 t f' <br />4. Date analysis- required by (if not Holding Time): <br />5. Special handling conditions or other instructions: =:z <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( <br />) If NO, explain: <br />QAC <br />Date <br /> <br />- --- - ?,.-- _,?:?..?..,.?.d.:...,..:__?...._. ,.._. _ ....... Page:31 of 36-