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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal iv - S we <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Caiion City, CO 81215 Cafion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. 4.1-1 P Lab. No.(s) <br />Sample Date Time 1, Date Data Entered <br />Collected By Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Delivered By <br />Received <br />Date Recd. <br />Time Recd. <br />?.v?wa V11?01[C LC?[1H8[IOH <br /> <br /> <br /> <br /> <br /> <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested:. l <br />3. Field Data -Preservation: A , <br />?' _ t 4' ? r' H ? ! ? ? ? 1 r .. C, G ! y ''? s?tj f • f ft r <br />4. Date analysis required by (if not Holding Time): _ <br />5. Special handling conditions or other instructions: <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 <br />Date <br />Page 31 of 38