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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal <br /> C: P.O. Box 1750 1 S, P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Canon City, CO 81215 Nucla,CO 81424 <br /> Sample LocJID No. 6(l Lab. No.(s) <br /> Sample Date �� Z r y Time v S Date Data Entered <br /> Collected By " f' v!ry Data Entry By <br /> Field Custodian -'. ; % e- + - Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination ���--- <br /> Energy Laboratories, Inc. <br /> Delivered By ���'� r f x 2393 Salt Creek H <br /> Received By j .'Jt� " Casper, Wy 82601� <br /> Date Recd. - <br /> Time Recd. i <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis- Test series requested: (a ! <br /> 3. Field Data-Preservation: A-oj <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 8 of 8 <br />