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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal li'112 S27100 <br />C: P.O. Box 1758 :IS: P.O. Box 1750 N: P.O. Boa 708 <br />Callon City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. <br />Sample Date �'' Tine -+ <br />Collected By <br />Field Custodian <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />�,eaavr <br />vaa -oaao a�suaawaavae <br />Lab. NoAs) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />+fir,. �( � � s •y • +' G <br />� — n <br />J <br />1. Sample Type: Air Water +�' Soil Other (specify): <br />2. Analysis- Test series requested: •' G� �.� , t <br />3. Field Data - Preservation: 4.1ty. 2w, ' .a. •' ' ' + L <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 rh <br />=NTS - Explanation of not items: ` +10 4'� e �-I— , �5 <br />,J^ - C CA <br />oe�% .je t�j' <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC <br />`770M <br />Page 22 of 23 <br />