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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal <br /> C: P.O.Box 1750 S: ` PA Box\1750, N: P.O. Box 700 <br /> Canon City, CO 81215 ' �. Callon City,CO 91215 Nucla, CO 81424 <br /> Sample LocJID No. _ 7 J Lab. No.(s) <br /> Sample Date 2 5 V Time 1 Date Data Entered <br /> Collected By } P ,l c Data Entry By <br /> Field Custodian /!0 (:' n #1 W t A Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination Energy Laboratories, Inc. <br /> �;, TLi <br /> -*, 2393 Salt Creek Hwy <br /> Delivered By — Casper, WY 82601 <br /> Received By �� r C" <br /> Date Reed. <br /> Time Reed. <br /> 1. Sample Type: Air Water J Soil Other (specify): <br /> 2. Analysis- Test series requested: x' <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 23 of 23 <br />