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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal '' ' S 17"G <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Cason City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. "' 6 Lab. No.(s) <br /> Sample Date L -2 S P` Time I/ �� Date Data Entered <br /> Collected By l�; b ��,.��..�7� Data Entry By <br /> Field Custodian Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By %� 'f, Energy Laboratories, Inc. <br /> 2393 Salt Creek Hwy <br /> Received By I"�'.: ,c; Casper, WY 82601 <br /> s <br /> Date Recd. V '' <br /> Time Recd. f r <br /> I. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis- Test series requested: f r <br /> 3. Field Data-Preservation: t S� �! r r /� w;+ , L <br /> ; t <br /> 4. Date analysis required by (if not Holding Time): <br /> S. 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 22 of 23 <br />