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COTTER C(WPORATION SAMPLE SUBMITTAL AND TRACKINGVORM <br /> Sample Submittal <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O.Box 700 <br /> Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. JA/ A t10 Lab. No.(s) <br /> Sample Date t -,2 - 1` f q T1me � 1"l Date Data Entered <br /> Collected By !3-' T r ':r'� `� ` Data Entry By <br /> Field Custodian f "''A.1 ' '" Laboratory Destination If not Cott— <br /> Cotter Off-Site Destination ek Energy Laboratories,Inc. <br /> AW <br /> y — <br /> Delivered By <br /> l� �r {.=rr — 3 exa1�NY e82601 y <br /> Received By P <br /> Date Reed. i'13 1 — <br /> b6o <br /> Time Reed. <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis- Test series requested: �'� c <br /> 3. Field Data-Preservation: <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 additional attachments. <br /> QA Review: <br /> Sample valid? YES ( ) NO ( ) If NO, explain: <br /> QAC Date <br />