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COTTER CYRPORATION SAMPLE SUBMITTAL AND TRACKIN FORM <br /> Sample Submittal •�. <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Cafion City, CO 81215 * Canon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. It1 f7 Lab. No.(s) <br /> Sample Date - � Time 1 • �0 Date Data Entered <br /> Collected By _ i '� , -1 Data Entry By <br /> Field Custodian <br /> y Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination — Energy Laboratories, Inc. <br /> t: {.f'b <br /> Delivered By 2393 Salt Creek Hwy <br /> — <br /> Casper, WY 82601 <br /> Received By �'�'• -" �`�'`�' � — �— <br /> Energy Laboratories, Inc. <br /> 1 ul-!1 <br /> Date Recd. -- - - - -- - <br /> Time Recd. 9aU <br /> r _ <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis- Test series requested: '` <br /> 3. Field Data -Preservation: _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 ( ) 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 /> arr.. QAC Date <br /> w� <br /> Ji- <br /> Page 32 of 38 <br />