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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal yj- c 2 5S3 7 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 91215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No./` Lab. No.(s) <br />a 'Z?Onme /a <br />Sample. Date <br />Collected By 9S O 4 <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />3. <br />Field Data - Preservation.: <br />7l <br />4.. Hate 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 />Date Data Entered <br />Data Entry By <br />Laboratory Destination K not Cotter:. <br /> <br />-Pag 32-of 38 <br />Type: Air Water I Soil Other (specify): <br />Analysis - Test series requested: && <br />Sample ---