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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal U"? R 2SS42 <br />Sample LocJID No. <br />Sample D#Ae )- 0.S ?,0// Time : d <br />Collected By Field Custodian- :T?•.w r -? <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Cafigp City, CO 81215 Cafion City, CO 81215 <br />a.oaaci- <br />,w,i?t Vll•OIIE LCS{IIIIIROII <br />' p? e.. <br /> <br /> <br /> <br />Lab. No.(s) <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br /> <br /> <br /> a <br /> <br />- ?a <br />1. Sample Type: Air Water _ Soil Other (specify): <br />2. Analysis - Test series requested: 'Cv':yQ. r <br />.3: Field Data - Preservation: - 7 9 d <br />e/ /74 A/ 0 <br />Delivered B <br />Received By <br />Date Recd. <br />Time Recd. <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />M: <br />i <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 /> <br />?t