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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal _ �� S6� T$ <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Caiion City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. 5 0 !4e,. P Lab. No.(s) <br />Sample Date '3- / 9- f Time <br />Collected By <br />Field Custodian /Lj.. <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />I.VL {G1 <br />Vll -�711C LC�i11RaROR <br />a. <br />ell- <br />1. Sample Type: Air Water <br />2. Analysis - Test series requested: <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />r <br />Soil Other (specify): <br />3. Field Data - Preservation: - T C �• zs „- ��. l �; : ,� / L, ; , % ; 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 <br />COMMENTS - Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />) and explain below. <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />QAC <br />Date <br />Page 8 of 8 <br />