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•64111•SVI <br />, J111 . 011C JPGEKIIIIIIIIM <br />.,1 <br />0 <br />, <br />i1-2 , 3-.2i) <br />/1 <br />LIM <br />A <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal S 25760 <br />C: P.O. Box 1750 <br />Callon City, CO 81215 <br />Sample Loc./ID No. Afk <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion,City, CO 81215 Nucla, CO 81424 <br />Lab. No.(s) <br />Sample Date 4 4 2 0 :1 ') Date Data Entered <br />Collected By f ,e Data Entry By <br />Field Custodian ,i-( Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />• <br />3. Field Data - Preservation: 5. 7 <br />c r Z p <br />. L. •:t 1 " <br />. 7 <br />• • _ <br />. • <br />; .(3 z 2, <br />-./ <br />1. Sample Tye: Air Water 6 Soil Other (specify): <br />/ <br />2. Analysis - Test series requested: / ' <br />iLyg. <br />(f l 4 / IV et 2 6 A I / <br />L , <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 22 of 23 <br />IA.-- ( <br />