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COTTER CO1tiORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />S81616 Submittal ` f I'f S 27M <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Cation City, CO 81215 C260n City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. I~ / � Lab. No.(s) <br />Sample Date 9 - 3 • "y Time //-,vi - <br />Collected By tf . <br />Field Custodian r. f"- .., <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />..V64WJL <br />��, -a�ie i,eseaauon <br />C/ <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination If not Cotter: <br />Energy Laboratories, Inc. <br />2393 Salt Creek Hwy <br />Casper, WY 82601 <br />2. Analysis - Test series requested:_ e� <br />+ _ . , .s <br />3. Field Data - Preservation: 1f 1 7. 5 3� S -4f <br />.r.�t <br />-x % "<. �: �/'F �'~{ ii' c•) '2.. �3f.•, i� <br />4. Date analysis required by (if not Bolding 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 It additional attachments. <br />QA Review: <br />Sample valid? YES( } NO( ) If NO, explain: <br />QAC <br />Date <br />Page 29 of 29 <br />