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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />C: ` P.O. Box 1750 <br />Csiora. City, CO 81215 <br />. Sample Loc./1E1 S <br />Sam* bete 't- n- /a. Time 1'1 4 1 5 <br />Coles By 1< d4 : r .74 <br />Field. Cutedian 4 7:4 A-0"i <br />Cotter Off-Site Destination <br />Delivered By4,,s,: e :64 <br />Received By ir,01 ,u <br />4 01 - It <br />Date Real. <br />Time Recd. <br />1. Sample Type: Air 1 . oil Other (specify): <br />2. Analysis - Test series requested: C J . / <br />3. F i e l d Data - Preservation: ro- *I. 8 er , I I 7 . +S JY 5 4 r cs <br />e r�r�' eO A , /• 6 .j.. Q# t ) 4 .5 , 1 # 4/0 3 i. 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 <br />QAC <br />Sample Submittal <br />• <br />S2U42 <br />S: P.O. Ben 1'150 <br />Canon City, CO 81215 <br />N: P.O. Box 700 <br />Nada, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />(, <br />lr /f or, ►'y A S 0 Q 7 a r C <br />Gv y 8 <br />) If NO, explain: <br />Date <br />Page-9 of 10 <br />