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‘....ULIVi <br />WIL•011V J.M.42111114514111111 <br />r <br />,-- er . ,.... , <br />tilisAL <br />6 <br />( / <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample Loc./ID No. 5 <br />Sample Date " .9 2" Time i :A Date Data Entered <br />Collected By i / 00.4 / Data Entry By <br />Field Custodian 11,4. 1 v".., "if t Laboratory Destination if not Cotter: <br />Delivered By <br />Received By <br />Date Recd. <br />Time Re . cd <br />C CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal . S Hen <br />2 . /C <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Nucla, CO 81424 <br />Lab. No.(s) <br />t <br />.1 <br />.r. 4 <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: t i <br />.3. Field Data - Preservation: /2 <br />7,77 2.72. 'a <br />72 54, i",e1 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: sky/ , . Viv • / 2 c <br />VC 4e / 7 <br />) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC Date <br />Rago 16 of 20,-- <br />