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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal_ x',-" S S94 <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br /> Sample Loc./ID No. Lab. No.(s) <br /> Sample Date > < ' ' '% Time t ? Date Data Entered <br /> Collected By �7^ j%' �+ �` Data Entry By <br /> Field Custodian f=Al/i`A � Laboratory Destination if not Cotter: ` <br /> Cotter Off-Site Destination - <br /> Energy Laboratories, Inc. <br /> Delivered By ;` "~ f y 2393 Salt Creek Hwy <br /> Received By Casper, WY 82601 <br /> Date Recd. <br /> Time Recd. 01 r 3 <br /> 1. Sample Type: Air Water X ;~ Soil Other (specify): <br /> 2. Analysis- Test series requested: 7-� h / ;'- <br /> 3. Field Data -Preservation: r `? /I "/ <br /> s <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 ( ) tf NO,explal n <br /> J - �►1 <br /> QAC Da <br /> v <br /> Page 25 of 25 <br />