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~• <br />r <br />Page ~ of - <br />MINED LAND RECLAMATION DIVISION <br />MONITORING FACT SHEET <br />LABORATORY SAMPLES <br />Operation: File Ik: (.- S ; -.71 ~ <br />Company/Address: Mine Contact: ~.,,, , <br />Specialist: - ~ y., <br />Date: Time: .~ f Weather:~i,a: <br />Comments: Laboratory: ' <br />1. Site ID.: ..~~~ '~,~r Location: ~ .~ <br />Full Ground Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw <br />Disposition: 1 ~~ ~ _ _ Time: , <br />Sample Split: Comments: <br />Flow/Level: pH:~Temp. EC. Other: _+ 1.. <br />2. 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. EC. Other: <br />3. 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. EC. Other: <br />4. Site ID.: Location: <br />Full Ground 4later/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw <br />Disposition: <br />me: <br />Sample Split: Comments: <br />Flow/Level: pH: Temp. EC. Other: <br />5. Site ID.: Location: <br />Full Ground Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw <br />Disposition• <br />Sample Split: <br />Time: <br />Comments: <br />Flow/Level: pH: Temp. EC, Other: <br />CHAIN OF CUSTODY <br />1. Transferred from: ~ ~ To: ~~ f~~•-~'"~Time/Date: "-'= ~i - l <br />1. Transferred from: To: Time/Date: <br />_~ <br />Received at Lab by: -~, _ '^~ Date: ~ ~ ~ ~' ~ ~ <br />r <br />8934F OOOYRMODYA <br />