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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal � ZO <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Cafion City, CO 81215 Nucla, CO 81424 <br /> Sample LocAD No._�,�y Lab. No.(s) <br /> Sample Date l f'i /�' Time a `+� S� Date Data Entered F' <br /> Collected By /{ ! �~�� / t Data Entry By <br /> Field Custodian i5 r'' ,,r S'. ;r Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination Energy Laboratories, Inc. <br /> Delivered By .l '} r" ! / ?393 Salt Creek Hwy <br /> ,per, 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:'-" '• f <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 additional attachments. <br /> QA Review: <br /> Sample valid? YES ( ) NO ( ) If NO, explain: <br /> QAC Date <br /> Page 17 of 20 <br />