Laserfiche WebLink
TION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal «: S 2707, <br />C: P.O. Boa 1756 S: P.O. Box 1750 N: P.O. Box 700 <br />Callon City, CO 81215 Callon City, CO 81215 Nucla, CO 81424 <br />Sample LocJID No. J01 -4 f Lab. No.(s) <br />Sample Date r'1 ' `i - / '! Time t �' . j <br />Collected By �' r� i di s .-? .T. <br />Field Custodian r._1 -! rt , <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.us�r <br />va�w�ac a,coNUiuva <br />L <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination If not Cotter: <br />— Energy Laboratories, Inc. <br />2393 Salt Creek Hwy <br />Casper, WY 82601 <br />C1 2 <br />r <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: !f <br />3. Field Da)ta - Preservation: "t. 16, / f <br />C!, 7 f *4v P I S sty J St <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 />f1 <br />QAC Date C <br />Page 14 of 14 <br />