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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal ::2 S?"4i <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion City, CO 81215 Cafion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. Lab. No.(s) <br />Sample Date f "' " " 4/ ' " Tlme I A ^ Date Data Entered <br />Collected `.By f ' '? ,ti f t Data Entry By <br />Field Custodian Laboratory Destination if not Cotter: <br />Delivered By <br />Received 16, <br />Date Recd. <br />Time Recd. <br />Cotter Off-Site Desrin <br />ahon <br /> / <br /> <br /> <br /> <br />1 fU <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: ' r <br />3. Field Data - Preservation: <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 Date <br />., . Page 32 of 38 <br /> <br />