2016-05-03_HYDROLOGY - C1981018 ‎(6)‎

• Permit No: C1981018
• IBM Index Class Name: Hydrology
• Doc Date: 5/3/2016
• Doc Name Note: ‎(CO0038024)‎
• Doc Name: 1st Quarter 2016 DMRS ‎(CO0038024)‎
• From: Blue Mountain Energy, Inc
• To: DRMS
• Annual Report Year: 2016
• Report Quarter_Month: 1
• Permit Index Doc Type: DMR’s
• Email Name: CCW
• Email Name: JRS
• Media Type: D
• Archive: No

TEST SUBSTANCE USAGE LOG
Project Number: 14001-436-017
Page 2 of -/
QA Form No. 041
Revision 5
Effective2/14
ai9: Aw7-11� I II,
Prennratinn of Tact SnliMo%nc
Test
Substance
Conc.
(% Effluent)
Sample 1
Sample 2
Sample 3
Sample 4
Test Substance Number
Total
Volume
(ml)
Test
Substance
Volume
(ml)
Dilution
Water
Volume
(ml)
Total
Volume
(ml)
Test Substance Collection
Date and Time
From? 104 1 C4
@ Ct71_J(.>
From:
@
From:
@
From:
@
To:
To:
To:
To:
Sample Type (Grab or Comp)
0%
0
100
100
Date Test Substance Received
�
Dilution Water Number
RW# or RE#, ircle one
50%
50
50
100
Concurrent Control Water RW#
Date(s) Used
100%
100
0
100
Prennratinn of Tact SnliMo%nc
Test
Substance
Conc.
(% Effluent)
Test
Substance
Volume
(ml)
Dilution
Water
Volume
(ml)
Total
Volume
(ml)
Test
Substance
Volume
(ml)
Dilution
Water
Volume
(ml)
Total
Volume
(ml)
Test
Substance
Volume
(ml)
Dilution
Water
Volume
(ml)
Total
Volume
(ml)
MH
0
0
100
0%
0
100
100
50%
50
50
100
100%
100
0
100
Total
150
150
F 400
Initials / Date
o t► ,r,.y�a� Tt A
Initials / Date
Initials / Date
Initials / Date
Initials / Date
Initials / Date
Initials / Date