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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />' - Sample Submittal`s <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. 9W ••% ,•4 - s" Lab. No.(s) <br />Sample Date 6 - 6 -2 013 Time <br />Collected By <br />Field Custodian % d 6 n G <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />1. <br />2. <br />a..va�ci <br />vu -�71�C 1/66 YiNUII <br />•�,� rte., <br />o J & <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />tQ+�-o.s <br />Sample Type: Air Water (Soil Other (specify): <br />Analysis - Test series requested: re, b / t" .2 _ <br />3. Field Data - Preservation: �� 3 D ,� Fi �Z.y <br />14 al--,4 �� Sit <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 />Page 21 of 21 <br />