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

CHAIN OF CUSTODY RECORD Laboratory Sample Numbers (ACZ Use Only): 1. ~ g,(~ Z COC q 0 `1i670~

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Optloro: Sw (Surleoa water) • GW (Ground water) • WW (wa9teweter) ~ DW (Drinking wafer) • sl (Sludge) • SOIL • OIL • otner (speedy) COMMENTS ~, ~~~
SAMPLE DISPOSAL OPTIONS -Please comp/eta asctlon A, or choose one optbn hom aecNons B AND C.
Proper ehsrpsa will ba assessed. '•
(/U Long-tsmr storage
Hold until (date)
for future analysis. I/ Sample /a Non-Hazardous
1 ocal Disposal
) RCRA -Permitted Facilely
3) Return to Client (C) Il Sample /s Hazardous
1 RCRA-Permitted Facility
2) Return to Client ,
RELINQUISHED BY: (SIGNATUR E) DATE TIM E RECEIVED BY: (S IGNATURE) DA E TIME PAGE q
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IV White -Return w! sample Yellow -Return w/ sample Pink -Return w/ sample Cora - rteep ror your recortls
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