2015-10-27_HYDROLOGY - C1981018

• Permit No: C1981018
• IBM Index Class Name: Hydrology
• Doc Date: 10/27/2015
• Doc Name: 3rd Quarter 2015 DMRS ‎(CO0038024)‎
• From: Blue Mountain Energy
• To: DRMS
• Permit Index Doc Type: DMR’s
• Email Name: CCW
• Email Name: JRS
• Media Type: D
• Archive: No

TEST SUBSTANCE USAGE LOG
Project Number: 14001-436-012
Page 2 of
FCETL QA Form No. 041
Revision 4
Effective 1196
Preparation of Test Solutions
Test
Substance
Cone.
(% Effluent)
Sam le 1
Sample 2
Sample 3
Sample 4
Test Substance Number
Total
Volume
(ml)
Test
Substance
Volume
(mi)
Dilution
Water
Volume
(ml)
Total
Volume
(ml)
Test Substance Collection
Date and Time
From: N41Q
S
From:
From:
From:
To:
@ g1
To:
To:
To:
Sample Type Grab or Comp
100%
1100
0
1100
Date Test Substance Received
2c,
Dilution Water Number
42) or TRE#, circle one
1I63i
Concurrent Control Water RW#
Date(s) Used
S
�U
lo'L tS
Preparation of Test Solutions
Test
Substance
Cone.
(% Effluent)
Test
Substance
Volume
(ml)
Dilution
Water
Volume
(ml)
Total
Volume
(ml)
Test
Substance
Volume
(m l)
Dilution
Water
Volume
ml)
Total
Volume
(ml)
Test
Substance
Volume
(mi)
Dilution
Water
Volume
(ml)
Total
Volume
(ml)
MH
0
1100
1100
100%
1100
0
1100
Total
1100
1100
2200
Initials Date
wMJw IWIS Nut
Initials t Dale
wh h ii
Initials ! Date
1012,115 t—
/ Date
WhyIninitials
(,Why-
itials / Date
Initials
Initials / Date
Initials /Date
w �" 1"112.115 F S Ae- I a h 3 115 4vr K -F 1 c_q--