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COTTER CORPORATION SAMPLE WSMITTAL AND. TRACKING FORM <br />Sample Submittal L" S 25524 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. J cf'? /4 0'? / Lab. No.(s) <br />Sample Date Time- <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.v"w! V11'01LC LCHIUMLWa <br />An..is?a: P : Y <br /> <br /> <br />•1 CY, <br /> ?o <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />r <br />-2 3 7 3 <br />02 6 a <br />rQ / <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: 1"c 4 Ar f <br />3. Field Data - Preservation: <br />I r.U- r .? r C. - :-_ J. 7. T S <br />1 .X <br /> <br />fib 7/ <br />b?G 4// 2. 4. Date analysis required by (if not Holding Time): _ <br />5. Special handling conditions or other instructions: <br />306 v s r"f <br />I G?fl? <br /> <br />;7\ <br />7 <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 <br />) and explain below. <br />) If NO, explain: <br />QAC <br />Date <br />Page 33 of 39 <br /> <br />