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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal fa S 2S""70 <br />1 <br />C: P.O. Box 1150 <br />Cason City, CO 81215 <br />Sampte Loc./ID No. S o roi. <br />Y/2°'1 . Tiate /3 5 O <br />Colley By . 404 /I .44 <br />Field Ctisaud1an Oa b .r...r:✓� .... <br />otter Mate Destination <br />Delivered `''By '6et�+ X"..0 P /r <br />te e <br />Date <br />Time Recd. <br />1, Sow& Type: Air Water Soli Other (specify): <br />Analysis - Test series requested: isi <br />• 4 <br />3. .Field Data — Preservation: _ <br />rr�f / 1(s 4 . "2 S ° l C7. C1 4 Nova 2.S' <br />k <br />4. Date . .sn.Iysis requirred. by (if not Holding Time): <br />5. Special handling traditions or .other instructions: <br />. U .. and 6. invalidating cirt?` ... If YES initial ( ) explain below. <br />CTNTS = Explanation • of noted items: <br />( ). Check if additional attadnnents. <br />QA ►- <br />S.mp1e valid? YES_ ( ) NO ( ) If NO, eXplain: <br />N: P.O.Box700 <br />Calton City, CO 81215 Nude, CO 81424 <br />S: P.O. Boat 1750 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Labo 'atory Destination if not Cotter: <br />? 3 9 3 Sc: t e r v2 ele 1/ <br />roc s , `Y. $ Z ‘ O Z <br />QAC Date <br />Page 20 of 20 <br />