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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal Nlei S2619" <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cafion City, Cg141 <br />CO 81215 Cafion City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. ;� Lab. No.(s) <br />Sample Date 1.7 .. Time 0, S O <br />Collected By �rl f 11��..t,•�` <br />Field Custodian Ie A 4 4 <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />\. -ulmV1 <br />VLl�OILG llCa�)Ui{�lVL <br />�J /". A'V r <br />9:3G <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />Z 3g3 Sc I> COF''r <br />, y 6 r <br />r <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: Ao <br />3. <br />4. <br />5. <br />Field Data - Preservation: ter' C� • �i h a J n 3 y �� <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial { <br />COMMENTS - Explanation of noted items: <br />) and explain below. <br />{ ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO( ) If NO, explain: <br />LN <br />Is �LLL7 <br />Date <br />Page 23 of 24 <br />