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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 1•113 S t5fiflo <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Cadon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. ?"', Q/ 0 L- Lab. No.(s) <br />Sample Date 1-19-2011 Time IO. 0 5- <br />Collected By o 4, <br />Field Custodian 4? Ss_? P.v ni G <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />3. <br />4. <br />5. <br />VVLLCI <br />o h Tv,.? i Vll'Olac licauuaasaVu <br />f r J 1 <br /> <br /> <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />?i , <br />( 1ye a.1 L4 Q/4 ?O? / r S 7.4, C. <br />?GS y, gz6oz_ <br />tr <br />N G <br />Sample Type: Air Water Q Soil Other (specify): <br />Analysis - Test series requested: <br />Field Data - Preservation: <br />Date analysis required by (if not Holding 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 <br />QAC <br />Date <br />Page 20 of 20 <br />) NO ( ) If NO, explain: <br />) and explain below. <br /> <br />