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<br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 'S.5639 <br />P.O: Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cason City, CO.81215 Cason City, CO 81215 Nucla, CO 81424 <br />Sample, LocJID No.. Lab. No.(s) <br />Sample Date ' 22 *2 AI/ Time <br />Collected By Aoyy 0,ed <br />Field Custodian B. 7p-r? <br />r?.. e. [HfAite nestin2tion <br />Delivered By DDk <br />Received 8y -7 <br />Date Recd. <br />Time Recd. <br /> <br />1. Sample Type: Air Water, <br />2. Analysis - Test series requested: t c <br />3. <br />4. <br />5. <br />Field Data - Preservation: <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Soil Other (specify): <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 /> <br />Date <br />Date .analysis required by (if not Holding Time): <br />Special handling conditions or other instructions: