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N...1/1M1 <br />J11 IICSIIU dLIUD <br />B r <br />• <br />Sample Loc. /ID No. / f f J P <br />C: P.O. Box 1750 <br />Canon City, CO 81215 <br />Sample Date 2 - /9 / Time <br />Collected By /. t, C).+ <br />Field Custodian '/ , <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />r 1 .t r, <br />QAC <br />Sample Submittal }1! S 167114 <br />• <br />S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 <br />/0 , 4 /0 <br />Laboratory Destination if not <br />^ ,p.C" �, <br />Date <br />Nucla, CO 81424 <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Cotter: <br />r <br />G. //- <br />1. Sample Type: Air Water / _ Soil Other (specify): <br />2. Analysis — Test series requested: l � ,/s / <br />3. Field Data — Preservation: T L 1. S g 7. 0.2. r' ' otOt338 <br />�. ZwlS f• J / z 5 `( � 5 (A/Vi (2, l- / /141 <br />7 5 <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 />Page 7 of 8 <br />