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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal , ..�.. <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Cafion City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. %�� fS j�J- Lab. No.(s) <br /> Sample Date Y Thne 10:I Date Data Entered <br /> Collected By Data Entry By <br /> Field Custodian t t`"'• r. Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination - -- - <br /> Energy Laboratories, Inc. <br /> Delivered By �` '`��'" �� 2393 Salt Creek Hwy <br /> Received By f.. Casper, WY 82601 <br /> Date Reed. <br /> Time Reed. <br /> 1. Sample Type: Air Water l Soil Other (specify): <br /> 2. Analysis- Test series requested: < <br /> 3. Field Data-Preservation: L •7 ' !.!Z of f . s•". 2 <br /> r <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 15 of 20 <br />