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COTTER Cftf1 6RATION SAMPLE SUWMITTAL AND TRACKING FORM O <br /> Sa�plenOmitta] It 91� <br /> C: P.O. Bog 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Callon City, CO 81215 J Canon City, CO 81215 Nucla, CO 81424 <br /> 1° <br /> Sample Loc./MNe. 4- Lab. No.(s) <br /> Sample Date Time - j 5.. Date Data Entered <br /> Collected By ' T�H��' 4 Data Entry By <br /> Field Custodian 7- L �i.aratary Destination if not Cotter: <br /> +tter Off-Site Destination Energy Laboratories,Inc. <br /> Delivered By IT fl4 y 2393 Salt Creek Hwy <br /> Casper, WY 82601 <br /> Received By �r' �Y ow �� <br /> Date Recd. 3DII�I <br /> Time Recd. <br /> 1. Sample Type: -Air Water _ ' Soil Other (specify): <br /> 2. Analysis - TeWeerlies requested <br /> X. Field Data-Preservation: T2. <br /> 7 <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 O and explain below. <br /> COMMENTS -Explanation of noted items: ' <br /> ( } Check if additional itiaifWft <br /> QA Review: - <br /> Sample valid? YES 1. I� NO ( ) NO,explain: ' <br /> (` J <br /> d <br /> QA' Date <br /> Page 13 of 20 <br />