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' qa ~ sa y <br />~ Page of <br />MINED LAND RECLAMATION DIVISION <br />MONITORING FACT SKEET <br />LABORATORY SAMPLES <br />Operation: File ~k: <br />Company/Address: Mine Contact: <br />Specialist: <br />Date: Time: Weather: <br />Comments: Laboratory: <br />1. Site ID.: <br />Location: <br />Full Cround Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw <br />Disposition• Time: <br />Sample Split: <br />Flow/Level: <br />2. Site ID.: <br />Comments: <br />Temp. EC. Other: <br />Location: <br />Full Ground ldater/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw <br />Disposition: Time: <br />Sample Split: Comments: <br />3 <br />Flow/Level: pH: Temp. EC. Other: <br />Site ID.: Location: <br />Full Ground Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw <br />Disposition: Time: <br />Sample Split: Comments: <br />Flow/Level: pH: Temp. <br />4. Site ID.: Location: <br />EC. Other: <br />Full Ground 4later/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw <br />Disposition: Time: <br />Sample Split: Comments: <br />Flow/Level: <br />5. Site ID.: <br />Temp. EC. Other: <br />Location: <br />Full Ground Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw <br />Disposition: <br />Sample Split: <br />Flow/Level: <br />CHAIN OF CUSTODY <br />1. Transferred from: <br />1. Transferred from: <br />Comments: <br />_pH: Temp. EC. <br />To: <br />To: <br />Other: <br />Time/Date: <br />Time/Date: <br />Time: <br />Received at Lab by:c/J Date: y -~/ ~ ~ <br />8934F OOOYRMODYA <br />