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COTTER CORPORATION SA PM LE SUBMITTAL AND TRACKING FORM <br />Sample Submittal :,�` s16$14 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. (�� / / Lab. No.(s) <br />Sample Date 7 • / i / -" Time /,,-). go <br />Collected By 4'1 ';5 <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />�-v«c, <br />vxi -onc ue�una�iun <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />1. Sample Type: Air Water _� Soil Other (specify): <br />2. Analysis — Test series requested: % r' Ic" l <br />3. Field Data — Preservation: T S •-,? //,Z. Z/,--) .-" ` < < L <br />i ., � <br />� S' f - � f, 7" CI . r _ <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 <br />Date <br />Page 7 of 8 <br />