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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal '11:2-1 SUM <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion City, CO 81215 Cafion City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. - 1 7 Lab. No.(s) <br />Sample Date y - %! Time <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a..Uibci <br />IJLL -01C IIC5LJHHtlUl1 <br />gH-ly-�3 <br />i oZ� <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />L <br />1. Sample Type: Air Water. t Soil Other (specify): <br />2. Analysis — Test series requested: %; �_ r�•. <br />r <br />3. Field Data — Preservatio/n: ` 1 /� 6 7 �5 <br />iiz7 22 <br />r% /V "j <br />f <br />✓ ` / L- <br />o <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? <br />YES ( ) NO( ) If NO, explain: <br />QAC Date <br />Page 21 of 21 <br />