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Sample Submittal ` _ Sfl <br /> C: P.O. Box 1750 S: P.O.Box 1750 <br /> Cason CIty, CO 81215 Cason City, CO 81215 N: P.O. Box 700 <br /> Nucla, CO 81424 <br /> Sample Loc./ID No. L',� J _ Lab. No.(s) <br /> Sample Date Time <br /> Date Data Entered <br /> Collected By J. 1 j. - Data Entry By <br /> Field Custodian ; ' I -f ,. , ; <br /> Laboratory Destination If not Cotter: <br /> Cotter Off-Site Destination <br /> Delivered By , r Energy Laboratories, Inc. <br /> Received By <br /> 2393 Salt Creek Hwy <br /> �f... �i�- - � Casper, WY 82601 <br /> Date Recd. ; —� <br /> Time Recd. <br /> 1. Sample <br /> p Type: Air Water Soil Other (specify): <br /> 2. Analysis— Test series requested: tom? J <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 <br /> 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 15 of 20 <br />