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COTT ION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal .Ll S?.Ti22 <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Callon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc.JID No. Lab. No.(s) <br /> Sample Date Time �f / S _ Date Data Entered <br /> Collected By ' r1.yp �* n Data Entry By <br /> Field Custodian t- >�' .?%lr 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 /> e, r <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis— Test series requested: t <br /> 3. Field Data—Preservation: r 7 , X.� - 3 C7 '�. L <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 19 of 20 <br />