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Sample Salw"�.._ <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 LocJW No. Lab. No.(s) <br /> Saft a Date -o ___ N Time bate Data Entered <br /> Collected By -47 ' /!'fit G-t Data Entry By <br /> Field Custodian � , �. " tea i Laboratory Destination if not Cotter: <br /> Cotter Off-Site Wination r.... rar c y Q. f <br /> Delivered By �%� "f_• -z ~� <br /> Received By j " �' s r� , dam' 'Z '� � C ' <br /> Date Reed. 5 <br /> Time Reed. 9 5 <br /> r . s,' .• <br /> 1. Sample Type: Air Water 1/_ Soil Other (specify): <br /> 2. Analysis— Test series requested: �rcl•� <br /> 3. Field Data—Preservation: o� /J. .�� .... 7 Dh <br /> f fr"r t � {'� r. • f, G• •�(_ � 4 �ti � �. ` �i j � �•�f �`r IV y� � } <br /> 4. Date analysis required by (if not Holding Time): <br /> 5. Special handling conditions or other instructions: <br /> 6. Invalidating circumst ? 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 /> Date <br /> Page 14 of 20 <br />