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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal LIZ <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Cafion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. Ik G!%' y" 13 Lab. No.(s) <br />Sample Date C' 15 1311ne VO <br />Collected By 4-z- T C. -n f <br />Field Custodian %3o <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />r� / .,�%F W1 <br />� >d� r ✓mss G 1 <br />vu -01e uebunation <br />�� <br />P <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />4s J r, / /C'.11 e-1 S 11 C <br />Z <br />-j G(. --of <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: jr2a 4 /e s;. <br />3. Field Data - Preservation: T Q <br />4. <br />5. <br />Date analysis required by (if not Holding Time): <br />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 23 of 24 <br />