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aa1VLMz ,UISMITTAL AND TRACKING FORM <br /> Sample Submittal #1,"' V <br /> C: 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 Loc./ID No. 1-1 0.7- Lab. No.(s) <br /> Sample Date ` Time 5 Date Data Entered <br /> Collected By 7 e- 1, c. -, _r Data Entry By <br /> Field Custodian �-`' � ►� f � f <br /> Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination , , i* <br /> Delivered By 7 1 /� . <br /> f <br /> Received By <br /> Date Reed. <br /> Time Reed. <br /> I. Sample Soil Other (specify): <br /> p Type: Air Water <br /> 2. Analysis - Test series requested: 7 -`e <br /> 3. Field Data-Preservation: <br /> 4. Date analysis required by (if not Holding 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 if additional attachments. <br /> QA Review: <br /> Sample valid? YES ( ) NO ( ) If NO, explain: <br /> QAC Date <br /> Page 9 of 15 <br />