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-�-- <br /> ORATION SAMPLE SUBMITTAL AND TRACKING FORM <br /> Sample Submittal Y! SOS 1_ <br /> C: P.O. Bog 1750 S: P.O.Box 1750 N: P.O. Box 700 <br /> Canon City, CO 81215 Cailon City, CO 81215 Nucla, CO 91424 <br /> Sample Loc./ID No. y G!r� �" " (? _ Lab. No.(s) <br /> Sample Date -l e j Time 9• ti 5 Date Data Entered <br /> Collected By r-- A f" __ Data Entry By <br /> Field Custodian 1 f+�i } Laboratory Destination if not Cotter: <br /> Cotter Off-Site Destination - - - - <br /> 1 Energy Laboratories, Inc. <br /> Delivered By Y r — 2393 Salt Creek Hwy <br /> Received By r �� _ Casper, WY 82601 <br /> Date Recd. — <br /> Time Recd. <br /> r <br /> 1. Sample Type: Air Rater � Soil Other (specify): <br /> 2. Analysis- Test series requested: f <br /> r <br /> 3. Field Data-Preservation: �� �' pf i Z o6 <br /> f <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 13 of 20 <br />