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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal _ SUM <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. &V Lab. No.(s) <br /> Sample Date Z' `af>>� Time Date Data Entered <br /> Collected By l ,ii +'r�.-r -z r Data Entry By <br /> Field Custodian Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Energy Laboratories, Inc. <br /> Delivered By 2393 Salt Creek Hwy <br /> Received By Casper, WY 82601 <br /> Date Recd. <br /> Time Recd. G ,f <br /> 1. Sample Type: Air Water f( Soil Other (specify): <br /> P f3'): <br /> 2. Analysis— Test serifs requested: <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 if additidnal attachments. <br /> QA Review: <br /> Sample valid? YES ( ) NO ( ) If NO, explain: <br /> QAC Date <br /> Page 37 of 38 <br />