Laserfiche WebLink
R CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal _ i S IM3 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Boa 700 <br />Callon City, CO 81215 Cation City, CO 81215 Nucla, CO 81424 <br />Sample LocJ D No. ! <-.l'4 (" 0 Lab. No.(s) <br />Sample Date _ �,� J lr Time `? <br />Collected By <br />Field Custodian Zf- <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />- ^� ,`• —'rte <br />1. Sample lrype: Air Water _7 Soil Other (specify): <br />2. Analysis - Test series requested: JT 6 /,- <br />3. Field Data - Preservation: <br />✓� ^ - .. � i ; �;j [ •'mot `i 1 J' � /J I�1r/j' £/„ �` i1 .�.-+ �� f � %`� <br />r <br />L <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 24 of 25 <br />%Y11-011C AMMUMUUM <br />gala Icy <br />q� <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br />- ^� ,`• —'rte <br />1. Sample lrype: Air Water _7 Soil Other (specify): <br />2. Analysis - Test series requested: JT 6 /,- <br />3. Field Data - Preservation: <br />✓� ^ - .. � i ; �;j [ •'mot `i 1 J' � /J I�1r/j' £/„ �` i1 .�.-+ �� f � %`� <br />r <br />L <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 24 of 25 <br />