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COTTER CORPORATION SAMPLE�SUBMITTA�LAND TRACKING FORM <br /> Sample Submittal <br /> : , -SUS17 <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 Nacla, CO 81424 <br /> Sample Loc./ID No. 'l Lab. NoAs) <br /> Sample Date i �' ' �` Time ,) •Q Date Data Entered <br /> Collected By t' Data Entry By <br /> Field Custodian Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination Energy Laboratories, Inc. <br /> Delivered By " �' 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: <br /> 4. Date analysis required by (if not Bolding 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 14 of 20 <br />