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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal lilry sin" <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./ID No. 1'ri R C ec" �� Lab.No.(s) L <br /> Sample Date 7",f, % � Time f Date Data Entered- <br /> Collected By �. " r�'�I +� '� Data Entry By <br /> Field Custodian 9% >` 1 e' rje_A Laboratory DestiHation if not Cotter: <br /> Cotter Off-Site Destination — ---- <br /> Energy Laboratories, Inc. <br /> Delivered By ' jr 2393 Salt Creek Hwy <br /> Received By Casper, WY 82601 <br /> Date Recd. <br /> Energy Laboratories, Inc. <br /> L <br /> Time Recd. w <br /> 1. Sample Type: Air Water S Sol] Other (specify): <br /> 2. Analysis— Test series requested: a <br /> 3. Field Data—Preservation: �f`( /�' ✓J [��J ^� 017 '{ L ' 4 <br /> n t'r3 r ' S i+�`��V p1, S e F.'- ^f ?S . is �aa. z .) t� 02M,2 <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 24 of 25 <br />