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1 4.APLWJI <br />%J11.011i IMUMAIIINVII <br />F 1� lc <br />Ai ley <br />Delivered By <br />Received By <br />Date Recd. <br />COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal NC. S 21497 <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Callon City, CO 81215 Callon City, CO 81215 <br />Sample Lor./ID No. 6 t-. 1 ,4 D Lab. No.(s) <br />Sample Date 6 — Time Pi 05 <br />Collected By g ka 13.4 of C <br />Field Custodian a6.4, 7:P i A C <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination y not Coyer: <br />r /ti pJ La i..• / ✓ / I - f 1 �. G <br />2.:T 4 - Cerjf l.'r t PK 4 - , <br />( pa y ? 160' Y <br />Time Recd. J <br />// . �.✓! c 1 <br />1. Sample Type: Air Water / Soil Other (specify): <br />2. Analysis - Test series requested: ( <br />QAC <br />3. Field Data - Preservation: r"- - $ /"I , /9 3 0 ` <br />a c�,�.� J �. 6 � • -� S' • ; 0. 5- �. F�f�'#V 2 C <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 />COMA'S -- Explanation of noted items: <br />( ) ebteit if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />Date <br />N: P.O. Box 700 <br />Nncla, CO 81424 <br />Page 7 of8 <br />