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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal r.-) Sims <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Cafion City, CO 81215 Cafion City, CO 81215 <br />Sample LocJID No. SIA69 Of (' J Lab. No.(s) _ <br />Sample Date I ` /$ --2011 Time /5 7/ 0 <br />Collected By & <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />%.U&Lcl <br />dEa 7o -w4 z0 vll- ALC ?cDNUaLNVu <br />?t <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />c ^,o op 5e L f-, 10 L2 e, 4, <br /> <br />Sample Type: Air Water Soil Other (specify): <br />Analysis - Test series requested: l n?.fl <br />3. Field Data - Preservation: / b? <br />e <'- 0- c/. /, ? u s <br />S t'? 0 d. 5-/ <br />4. <br />5. <br />v 7 75` rV -J--2s1? U s ¢'/7i 3-' <br />4. S L. /=?411A1!J ?. 5 <br />Date analysis required by (if not Bolding Time): . <br />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 15 of 20 <br />) and explain below. <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />