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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal �!1!1 S 24 <br /> C: P.O. Box 1750 S: P.O.Box 1750 <br /> Canon City, CO 81215 N: P.O. Box 700 <br /> Cation City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. r,(,'—/ !'AL Lab. No.(s) <br /> Sample Date — f 4V Time ! d Date Data Entered <br /> Collected By f7 r <br /> Data Entry By <br /> Field Custodian � Laboratory Destination if not Cotter: <br /> Cotter Off-SIte Destination _ <br /> Delivered By ;,< / Energy Laboratories, Inc. <br /> — 2393 Salt Creek Hwy <br /> Received By %' " rat ,• lz� _ Casper, WY 82601 <br /> Date Recd. a <br /> Time Recd. <br /> 1. Sample <br /> p Type: Air Water Soil Others eci <br /> ( p fy): <br /> 2. Analysis— Test series requested: <br /> 3. Field Data—Preservation: / <br /> 4. Date analysis required by (if not Holding Time): <br /> 5. Special handling conditions orether hotructions: <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 Date <br /> Page 17 of 20 <br />