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OF, <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 25446 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Cafion City, CO 81215 Nucla, CO 81424 <br />1qj t-? Lab. No.(s) <br />Sample Loc./ID No. - <br />Sample Date Time Date Data Entered <br />Collected By Data Entry By <br />Field Custodian . f Laboratory Destination if not Cotter: <br />Cotter Off-Site Destination <br />Delivered By r <' <br />? r <br />Receive !/? &c / <br />Date Recd, i?• / b?f <br />`. Time Recd. <br />1. Sample Type: Air Water Soil Other (specify): <br />c'A <br />2. Analysis - Test series requested: <br />3. Field Data - Preservation: <br />? t rr:K.• C ?- J!. 7. S f ?_! fj ':?` ? - ?'' ( ? ,,'f ,!-'i'?j?:- t ?' ` ,?-, <br />r4. 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 37 of 33 <br />i <br />