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%1ORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Samile Submittal _ L <br />.,. 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 LocJID No, 1W lf. 11 Lab. No.(s) _ <br />Sample Date 12. - I I <br />Collected By -Dw l'el <br />Field Custodian -0. e <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />ey M <br />vai -Otte Imunanon <br />14 ` <br />G <br />g `lam <br />Date Data Entered -� <br />Data Entry By <br />Laboratory Destination <br />L if not Cotter: <br />5 <br />1. Sample Type: Air Water Other (specify): <br />2. Analysis - Test series requested: A J<.-' <br />! <br />3. Field Data - Preservation: � �` <br />C>/.p 9011 <br />!L-OF L � <br />14'3 <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: ''f e _ — 1141 +- 2-05 <br />{ ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES <br />QAC <br />) NO ( <br />I <br />} If NO, explain: <br />Date <br />t - <br />Page 14 of 14 <br />