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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal I S�� Y <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Callon City, C(O� 81215 Canon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. J /J !/ Lab. No.(s) <br /> Sample Date 6 -2 , 4�1t " Time Date Data Entered <br /> Collected By �� ?�"^ 1 Data Entry By <br /> Field Custodian Laboratory Destination if not Cotter: <br /> Cotters Off-Site Destination Energy Laboratories, Inc. <br /> Delivered By '`� I l-r�; r cy 2393 Salt Creek Hwy <br /> Casper, WY 82601 <br /> Received By <br /> Date Reed. <br /> Time Reed. / . <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis- Test series requested: <br /> 3. Field Data-Preservation: 1 <br /> 1 <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 /> QAC Date <br /> Page 34 of 38 <br />