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COTTER CORPORATION SAMPLE SUBM� ND TRACKING FORM <br /> Sample Submittal 7 t S t i <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O.Box 700 <br /> Canon City, CO 81215 Caiion City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. / Lab. No.(s) <br /> Sample Date <� " / Time 00 Date Data Entered <br /> Collected By Data Entry By <br /> Field Custodian _ / - �� " �• - Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination - - --. - - <br /> Energy Laboratories, Inc. <br /> Delivered By '_`.; — 2393 Salt Creek Hwy <br /> Received By <br /> ll' Casper, WY 82601 <br /> — <br /> Date Recd.Time Recd. <br /> 1. Sample e• Air Water Soil Other (specify): <br /> P n'P A <br /> 2. Analysis- Test series requested: <br /> K. <br /> 3. Field Data-Preservation: - i ; ' � ! d . C <br /> f'• f !Z l f !I�, Ir �.. fJ G._ x�/- LI <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 18 of 20 <br />