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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal NS $ 25706 <br />C: LO. Box 1750 <br />Callon City, CO 81215 <br />Sasnple Loc./ID No. as. <br />Sample Date 1 1 - - 20# Time /1 ° <br />Collected By <br />Field Custodian /Yak 4 <br />Cotter Off.Site Destination <br />Delivered By 44 te# <br />Received By <br />Date Recd. <br />Time Recd. lete•D <br />Atdi <br />1. Sample Type: Air Water / Soil <br />2. Ands - Test series requested: ( <br />3• field Data - Preservadon: rot- C f el,/ 5. �S a 7/ s-- • <br />, g 3/.44 el-fis- ac- (;, S A N/VO r <br />4. Date analysis required by (if not Holding Time): <br />5. Special handling conditions or other instructions: <br />6. Invididating circumstances? If YES Initial ( <br />COMMEN1t- Eiplanitien of noted items: <br />( ) Check if additional attachments., <br />QA Review: <br />Sample valid? YES.( ) NO ( ) If NO, explain: <br />S: P.O. Box 1750 <br />Cation City, CO 81215 <br />N: P.O. Box 700 <br />Nude, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />7 to 5 1 c, <br />7 93 S el/ er.e <br />n tf(17 ce 6 <br />QAC ' Date <br />Other (specify): <br />) and explain below. <br />• <br />• <br />_ <br />_ <br />Page 17 of 20 <br />