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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal : R 26376 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br />Sample . oc. /ID No. ✓ A 41 6 Lab. No.(s) <br />Sample Date $ -/ ' /2 Time /I : a 0 <br />Collected By 2SO 6 re,, ++• c <br />Field Cuistodian go 6 744 #4 c �a f <br />Cotter Off -Site Destination <br />Delivered By Od 1 l �e / �, ' 4.s civ i,s} <br />Received By ice efi fr ice- RAM- <br />Date Read. S --,Z -1 a- <br />nise Recd. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />A^ <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: 4 ,4 /4, / <br />3. Meld Data - Preservation: 7• D v • • g 233 ` r Q j . " 0- <br />Air <br />/+L` /C' /" /4// U 2 /I 1PA,V O <br />,ra y S , » � . . � 1 , 0 S - L Lf A , .c off 2, 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 ( ) If NO, explain: <br />Page 28 of 29 <br />