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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />C: P.O. Box 1750 S: P.O. Box 1750 <br />Caiion City, CO 81215 CaAon City, CO 81215 N: P.O. Box 700 <br />f Nucla, CO 81424 <br />Sample Loc./ID No. �� - At WD— Lab. No.(s) <br />Sample Date -S' L4 - G Time Q �✓�- <br />Collected By C '/ <br />.l P% M [ 1 Id <br />Field Custodian t) u>) P� t {, Ir0% <br />Delivered <br />Received l <br />Date Recd <br />Time Recd <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />73 - 1+ ,-aeh } -E -K/Y <br />t.,/ Z.Go <br />e, 1i4 -1 OIL <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: 4 <br />3. Field Data - Preservation: t +�� , ��6 pj''i� L1201 (j-s' Z'5 <br />0,S o v -A V-4 01-4 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 />QAC <br />Date <br />— -09900' Page 28 of 29 <br />