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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 1-12- s261920 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Bog 700 <br />Canon City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample Loc. /ID No. M W 1r <br />Sample Date _( -- IS ^" /3 Tune 00 <br />Collected By i8 o �F'ry t ' <br />Field Custodian Z Z, o 6 /d.n 'A i n <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />% -U &LCI <br />VAI'OALO LMDUUsuvu <br />k <br />Lab. No.(s) <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: 1 G Z J-e Z <br />3. Field Data - Preservation: <br />4. <br />A� <br />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 />If"I?� <br />Page 24 of 24 <br />LS 't. <br />