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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal •t�, <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 0 <br /> Cation City, CO 81215 Cation City,CO 81215 Nucla,C 1424 <br /> Sample Loc./ID No. �_, C Lab. No.(s) _ -► <br /> Sample Date +� Time 0 Date Data Entered <br /> Collected By 7 `{' f 'r'"'A r.1 f Data Entry By <br /> Field Custodian ' ' ``�� �" ^ Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination Energy Laboratories, Inc. <br /> Delivered By ai�' r f -` 2393 Salt Creek Hwy <br /> Received By ,,., f �,� Casper, WY 82601 <br /> Date Recd. <br /> Time Recd. qau <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis - Test series requested: a '� <br /> 3. Field Data-Preservation: T - �S # 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 /> i <br /> ( ) Check if additional attachments. <br /> QA Review: <br /> Sample valid? YES ( } NO ( ) If NO, explain: <br /> — QAC <br /> Date <br /> v , <br /> 7 <br /> Page 38 of 38 <br />