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COTTER CORPORATIO MPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal : S 17S 1! <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. __ Lab. No.(s) <br /> Sample Date /, - ' /c/ Time 0• Date Data Entered <br /> Collected By `�: -- '�t. f Data Entry By <br /> Field Custodian pl zf r' Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination — — <br /> Delivered B Energy Laboratories, Inc. <br /> y r 2393 Salt Creek Hwy <br /> Received By ` Casper. WY 82601 <br /> Date Reed. <br /> Time Reed. r, <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis — Test series requested: <br /> 3. Field Data—Preservation: -6 2 - <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 16 of 20 <br />