PERMFILE47357

• Permit No: M2001063
• IBM Index Class Name: Permit File
• Doc Date: 6/22/2001
• Doc Name: LIMITED IMPACT OPERATION 110 2 RECLAMATION PERMIT APPLICATION FORM
• Media Type: D
• Archive: No

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A SAMPLE RECEIPT FORM
CLIENT: ~( /~
PROJECT e: L I t( L Page I oft

_...._DATE---~ - -oo_._
l) Don this project roquire special handling procedures such as CLP protocol? YES NO
2) Arc the custody seals oa the cooler intacCt ~ YES NO
3) Are the ctutody swls on the sample containers intact? ~ YES NO
4) is [here a Chain of Custody (COC), or other directive hipping papers present? ~ NO
5) Is the COC complete?
Rel'taquished? Ya No Reque3ted Analysis? Ya
""No ~ NO
6) TS the COC in agreement with the satnpla received?
u of Samples: Ya _ No _ - Sample lD: Ya _
Matrix: Yes No N ofContainers: Ya
No _
No ~ NO
7) Is there enough sample for all requested analysis? NO
8) Are all samples within holding times for requested analysis? NO
9) Were all sample containers received intact? NO
l0) Arc samples requiring no headspace, headspace &ee? YES NO
1 l) Do the samples require a Foriegn Soib Permit Label ar q~~-~^~~e? YES
l2) Do samples require special disposal/hold considerations?
Non-Hazardotu: Yes No
azardous: Yes No
H
Hold: months
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Des~ibe "NO" it nts (except kl, l 1, & 12): ~dy NuTL llff~ ~ Tw.-
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Was the client contacted? Ya No
If yes: Date: _ Name of person contacted:
Actions taken or client instructions: .r

Signature:
FRMQMt l.111.97.t)t
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