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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />14+2 <br />Sample Submittal <br />C: P.O. Box 1750 S: P.O. Box 1150 N: P.O. Box 700 <br />Cafion City, CO 81215 Cafion City, CO 81215 Nucla, CO 81424 <br />Sample LocJiD No. W 0 5 Lab. No-(s) <br />Sample Date yQ <br />Collected By <br />Field Custodian 'de4 ?Q a??? a n' <br />Delivered By <br />Received By <br />Date Recd. <br />Time-Recd. <br />%.:oaer <br /> <br />T Vaa'4aw srwu..••.•.,.. <br />r <br />? <br /> <br /> <br /> a1L1S <br />Date Data Entered <br />Data Entry By <br />. <br />Laboratory Destination if not Cotter: <br />/4 law r. fool, <br />2 3 `3 3 Sr / G Irv 4e. <br /> <br />1. Sample Type: Air Water - I Soil Other (specify): <br />2. Analysis - Test series requested: _ <br />3. <br /> <br />01- <br />i <br />Field D *- <br />a - <br />4. rvatlon• <br />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 />i <br />_? ?- - -- -------- <br />QAC <br />) and explain below. <br />Date <br />--- --_ =- ----- - -__ --.-. --Page-3- nf-38-