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14.ALISIML <br />Ull.011.11E /PC111/1111111,11 <br />A <br />• <br />Suppla Loc./ID No. Scli /IC <br />0 1 i 404 BY <br />C: P.O. lox 1730 <br />Odom City, CO 81315 Canon City, CO.81215 <br />a t e ; Z /7 5 flmelZ:5 <br />- <br />- WIS,,,-4010Mareafon: 7 /‘ "4 7.'17 (7.J 170 <br />c 7,7,4 A 4.. 4..c. I <br />,A **0 14elesi_ e <br />■-■ a a aa am. V MM.{ MI.1. .VIORA. • s4 =AV.. aa 4. V./mm.4w." a "47.. ; ‘1114, so a aarlIM.,111.1.4.4 •4..• a V WIWI& <br />, • <br />6 ' <br />Type: Air Water - Soil Other (specify): <br />- Test series requested: <br />fate analysis required by (if not folding Time): <br />handling conditions or odour instructions: <br />f • ) Chock if adintional attachments. <br />QA. frifieW: <br />Etna* van14? YES( ) NO ( ) If NO, explain:1 <br />Sample Sibmittal 1 San* <br />QAC Date <br />S: •P.O. Box 1750 <br />Date Data Entered <br />Data Entry Ey <br />Laboratory Destination if net Cotter: <br />6 r 4. •4 <br />7 3 IS <br />Lab. No.(s) <br />N: P.O. lox 74141 <br />Ne011111434 <br />C f <br />circumstances? If YES initial ( ) and explain below. <br />plonatlo of noted items: <br />Page 9 of 9 <br />"r. <br />