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Sample Loc./ID.No. OS <br />Sample Date 7 7 ' 20// Time 7 J-5-- <br />Collected B y tg0 b ita.v <br />Field Custodian .? n4 IOW ,✓a -Let <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. Sample Type: <br />Cotter <br />get 4 <br />Off-Site Destination <br />Areri <br />' COTTER' CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sampler Submittal o S 21194 <br />C: P.O Box 1758 S: P. Box 1759 <br />Callon City, CO 81215 Callon City, CO 81215 <br />Air //�� / <br />2. Analysis - Test series requested: C- 34 <br />P.O. Box 700 <br />Nudist, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination U not Cotter: <br />jV so..s e li . O ar Tor: r► S . <br />7343 ScJt L°✓ j • y • <br />CI f 4,44 gze C/7 <br />l0 <br />Water , Soli Other (specify): <br />Field Data: - Preservation: T er 16 .0 N '7. d. e A- J. i f O u S G 'r <br />rl vfia ' r'_sAI . /7 14,5 r s` Z. f frlx/ 7 2 5,0-la <br />1 0 . <br />Date analysis regrilred by (if not Holding Time): <br />f . Special handling conditions or other instructions: _ <br />: b. Invalidating circumstances? If YES initial ( ) and explain below. <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />S*mple valid? YES ( ) NO ( ) If NO, explain: <br />QAC Date <br />Page 37 of 39 <br />