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COTTER CORPORATION SAMPLE SUBMITTAL AND. TRACKING FORM <br />Sample Submittal i ,' o S 2 5 5 2 3 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. S(AI'4 tcl /) Lab. No.(s) <br />Sample Date Time j O' 3 !? <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />VV1lCl Vll'OAC L <br />CSLUIiUVL <br /> , <br />Y <br /> <br /> <br /> 0 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />7 C' /"? JJ <br />70 <br /> <br />Sample Type: Air Water_ Soil Other (specify): <br />Analysis - Test series requested: f <br />3. Field Data - Preservation: r o <br />s? / / ,J ?/? ? ] • <br />1 /Z /9' S L. / /A •, /T /r+ Lf J ti cvf <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 />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />Date <br />Page 32 of 39 <br />) and explain below. <br />