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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 11! S25 699 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Cason City, CO 81215 Ca8on City, CO 81215 <br />Sample Loc./ID No. <br />Time Recd. t(j'O t? <br />1e/13 <br />Sample Date y — 6 , ' 2 / Time /• 3 <br />Collected By /2 re.e sf/G <br />Field Custodian. <br />Cotter Off -Site Destination <br />Delivered By e & C / ✓ . . - N . . . , 1 / pj % <br />Received By . re j� <br />Date Recd. 5 •y �� 4.1-0 <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />t` /✓ C1r 41T L6 taw I P S <br />�3 <br />2 3 9} � cr r <br />c g' G v2 <br />1, Sample Type: Air Water 2 Soil Other (specify): <br />2. Analysis — Test series requested: T /c 1 <br />°` 5 -0 / 'f 7 3P i9 e s 1� <br />3. Field Data — Preservation: .•� r✓T s <br />ri�SQ ee Z. /4 4,7Cs..0 % SfQ /l. f f= /vi'a 70i-. <br />/ L C , /f s t,�F,q,/ l 2 5 ;,.,o 4r f ,/- 44s'e, <br />s 5 V/ 4/4 Oft 2. S -� <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 43 of 43 <br />