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Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 2 s25791 <br />C: P.O. Box 1750 S: <br />Cation City, CO 81215 <br />Sample Loc./ID No. .. e!1 PL <br />Sample Date 3 2 c7 if Time /.A 3 <br />Collected By /1-50‘ 74 <br />Field Custodian Boy 14 4 4 t <br />Cotter Off -Site Destination <br />/ -e,n <br />/(')OCR <br />Sample Type: Air Water / 4 ' Soil <br />Analysis- Test series requested: ( -. cfp / <br />3. Field Data - Preservation: / y <br />'....._ s 2 ./.2 <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 ( <br />QAC <br />P.O. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 Nucla, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />er4 toe c. <br />2 3 S 3 5 /l /1' , 44., . <br />r » /t/7, C' Z 6 0 .Z <br />Other (specify): <br />h' 7- 7/ r) v 7 /2 , c d t , <br />! ///4-4- z 2 <br />) If NO, explain: <br />Date <br />Page 16 of 20 <br />