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Sample Loc. /ID No. <br />Sample Date $ ' 2 20// rime / y 4' <br />Collected By 13 ' '-- 7 G " 71 <br />Field Custodian ,) / 76:" Af'a1 ti f <br />Cotter <br />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 y2 s25795 <br />C: P.O. Box 1750 <br />Callon City, CO 81215 <br />S: <br />Off -Site Destination <br />Sample Type: Air Water I Soil <br />Analysis - Test series requested: 'J <br />6. Invalidating circumstances? If YES initial ( <br />QAC <br />P.O. Box 1750 N: P.O. Box 700 <br />Cafion 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 />A {�"•vP. bC>r 4 taIr w'S iv . <br />?3 -Celt Cr0. P G /> �,S,, <br />s p l ( et/ V, zvz <br />Date <br />Other (specify): <br />3. Field Data - Presery tion: y Z/ i� �7 1• S'o �a"` d - 2 2 o cc Sal'L f 4 <br />// s f !'d .,.c 2. rd l z S 2 S G G% ;, z <br />,5,,e c l <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />) 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 />.rado <br />Pogo 20 of 20 <br />