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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> SampleS4ftl t sTA S <br /> ._ _ <br /> C: P.O. Box 1750 U S: P.O.Box 1750 N: P.O.Box 700 <br /> Cation City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br /> Sample LocAD No. ,-,J t7 Lab. No.(s) <br /> Sample Date "> Time 9 4? Date Data Entered <br /> Collected By -� `� �'� o+ Data Entry By <br /> Field Custodian Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination EnergY L~' <br /> 'l . , t, ;f aboratori tnc~------ <br /> ----------Delivered By 7 ?3 ne Salt Creek Hwy <br /> , <br /> Received By r ^,'�f f Casper' W y 82601 <br /> Date Recd. L <br /> Time Recd. <br /> 1. Sample Type: Air Water � Soil Other (specify): <br /> 2. Analysis-- Test series requested: r>.�//. <br /> 3. Field Data—Preservation: / S 7„-, �� 7.2 a 2 9 c t r <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 7 of 8 <br />