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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i S26560 <br />C: P.O. Box 1750 S: P.O. Box 1150 N: P.O. Box 700 <br />Callon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. <141o- a Lab. No.(s) <br />Sample Date Z ' ?'•? of / . Time <br />Collected Byo S f?'??r'e?.". <br />Field Custodian 4 r <br />Delivered By <br />Received By <br />Date Recd.. <br />Time Recd. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Z4 r <br />'J iAf <br />e.? <br />l.. Sample Type: Air Water ff Soil Other (specify): <br />2. Analysis - Test series requested:- <br />3. <br />4. <br />5. <br />Field Data - Preservation: 7 n v. IF L.vv r " . AWL k:f2 44 z .1 02 <br />air, I i . <br />6. Invalidating circumstances? If YES initial ( ) and explain below. <br />COMMENTS - Explanation of noted items:. <br />i <br />i <br />i <br />( ) Check If additional attachments. <br />QA Review; <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />I <br />QAC Date . <br />-------- - - -_ -- - --- --- -- -- -- image 'f9 of 2-0 <br /> <br />Date: analysis required by (if not Holding Time): - <br />Special handling conditions or other instructions: