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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal i :° S2633 <br />C: P.O. Box 1750 S: <br />Cation City, CO 81215 <br />Sample Loc./ID No. 54/ I PZ- <br />Sample Date 5 / — /2, Time <br />Collected By , v C �7 . r! e4 1t f <br />7 � <br />Field Custodian X0 6 " -► * n <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Cotter Of[ Site Destination <br />3. Field Data - Preservation: 7 -01-- <br />P.O. Box 1750 N: P.O. Boa 710 <br />Cafion City, CO 81215 Nucla, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotte : <br />/ '1Pv La a, fJr JA. <br />73 93 � } 5 /f" re 9 we 4 //4 y, <br />C?.d . i/) g ? c a, <br />1. Sample Type: Air Water 1 Soil Other (specify): <br />2. Analysis - Teat series requested: rd. 4 i t . <br />a J. 4,55a(t <br />/1f , k 7 s 6-/J( /14't/ ��- /� �/F 144e 4,11, 0 <br />L /4,t1 0# 7, 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 />QAC Date <br />Page 29 of 29 <br />