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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i,i°_ S ISS71 <br />C: P.O. Box 1750 S: P.O. Box 1754 N: P.O. Box 700 <br />Cafion City, CO 81215 Cason City, CO 81215 Nucla, CO 81424 <br />Sample LocAD No. Lab. No-(S) <br />Sample Date ?"+2 S -??{ Time <br />Collected By A o ? ?P,rvr? c <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />.2. <br />Date Data Entered <br />Data Entry By <br />ter: <br />Laboratory Destination if not vd:*-,f <br />G <br />X11/ ?Ct isvId*. p/ <br />. <br />2- o?7? G.?1 ?rtGK C%./ Le <br /> <br />Sample Type: Air Water Soil Other (specify): <br />Analysis- Test series requested: //?? C lAr <br />3. Field Data - <br />4. <br />5. <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 />Page 38 of 39 <br />Date analysis required by (if not Holding Time): <br />Special handling conditions or other instructions: -