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L.V11L'l% <.VnIVAtfliVl\ OLiLYli LL' �_✓UIl L,J6ilL fil\L LAl•1\..i111\V 1'VAla <br /> Sample Submittal <br /> C: P.O. Box 1750 S: P.O.Box 1750 N: P.O.Box 700 <br /> Callon City, C�O+81215 Callon City, CO 81215 Nucla, CO 81424 <br /> Sample LocJID No. 7' � Lab. No.(s) <br /> Sample Date S _ Time f. Date Data Entered <br /> Collected By Ja . f.. 1 `�',� t ! _ Data Entry By <br /> Field Custodian Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination j• . u ! : E <br /> Delivered By! / , ' t' r. =:, r y r <br /> Received By / <br /> Date Reed. <br /> Time Reed. 1 f <br /> 1. Sample Type: Air Water Soil Other (specify): <br /> 2. Analysis— Test series requested: `� 1 <br /> 3. Field Data—Preservation: <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 20 of 23 <br />