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<br />DEPARTMENT OF THE INTERIOR <br />OFFICE nF SUBFACE MININ~3 <br />CHAIN OF CUSTODY <br />I, ( Y_ , have received <br /> /}"1(.-- ~d7-C ~?E •~'/ l~ ~ /-3 from <br />oP Samples Sample Numbers <br />/ <br />~ <br />' ~ y(/~ ~ ~ <br />' <br />on ' <br />c <br />~ <br />' <br />. <br />n~fR1 ~, ~(, <br />i~ V <br />Gi /' <br />c <br />`. XrC Pr c~ <br />f <br />Name and Title Date <br /> /~. <br />at <br />/i <br />'~U <br />` <br />~ <br />n ;/ <br />- <br /> ~,: ~c,~ 1L <br />.:. <br />.L~i/.c <br />~.c.~,~ ~CN n~ . <br />u.~!:. <br />Time P1'ace <br />Source of Sai:ioles: <br />Name of Coal Co. i '_ <br />Location:_1Gi~~~,~ ,',,. i'',~;iL'. <br />~~ , , <br />,~ 1~` ~-~ <br />G' . c ~~i ~ <br />Signature gf/Sample Submitter <br />C / <br />Signature of Sample Receiver <br />