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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 12 S2.SAR3 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Cason City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No:t Lab. No.(s) <br />Sample Date S ' Time y <br />s-? t -? <br />Collected By <br />Field Custodian s { •'.+ .+« ?- <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />liI?LLCi" Vll-Qiac ucecauaaivu <br />f?'?( <br /> <br /> UIL <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />ry <br />?zz <br />i .. <br />6. +. <br />1. Sample Type: Air Water J% Soil Other (specify): <br />2. Analysis - Test series requested: ^/' { <br />3. <br />f' <br />i <br />k <br />Field Data - Preservation: <br />C . !&.- <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 />and explain below.,;. <br />{ ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br /> <br />QAC Date