HYDRO20165

• Permit No: M1977208
• IBM Index Class Name: Hydrology
• Doc Date: 8/2/2004
• Doc Name: Water Samples of 07/02/04
• From: Paragon Analytics
• To: CEMEX Inc.
• Media Type: D
• Archive: No

Paragon Analyfics
CONDITION OF SAMPLE UPON RECEIPT FORM
Client: ~ L M L x J-,~c_. Workorder No: ~~ O ~U.3
Project Manager: I_nr ~ V'ac.~-Par- Initials:~_ Date: ~ 2 Dy
Additional Information:
Was the laboratory directed to proceed with the analysis of any samples yielding the presence of residual chlorine? YES / NO / NA
NOTE:
No pH adjustments shall be made without prior consent of Project Manager. After pH adjustments, hold metals
and radchem samples 2 16 hrs. before analysis.
Was the pH of any sample adjusted by the laboratory? YES (See Table below) / NO
pH Excursion:

Sample ID
Client ID
Initial pH
Final pH
Reagent
Used Volume
Added
(~)
Lo[ No. of
Reagent
Requuted
Aua~Ysis
Initials /Dale /Time
D D ~ - 1 - (~,+ I ~ ? Nu(73 3 Yw4'f Me+.lf J i(i~''1 Isoo
4J ~'3}-1 C'~ P. •• I~ N~ I~ 9z~`I ruftk,,, *I~ av /seo

If applicable, was the client contacted? YES / NO / Cli/ent/Rep,. `Name: Date/Time:
Project Manager Signature/ Date: ~ 1 l `l~~ ~7
Form 201 r18.x15 (6/26104)
Page ~ of .Z
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