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~, • • iii iiiiiiiiniiiiii <br />MINED LAND RECLAMATION DIVISION <br />M N N HEE <br />Operation: - File #: ' ~ `i <br />Company/Address: , . , Z '_ <br />Specialist: . <br />Date: ~la __ tme: ~ Weather: „ - ,.., <br />General Location: <br />General Comments: <br />II. Laboratorv Samples <br />1. Si a ocation: <br />Lab: Parameters:' Description: <br />Disposition: Grab/Composite: <br />Sample Split: omments: <br />Flow/Level: y; ~.~SpH:, ,y Temp. ;-•-~ EC.• , /c. ; Other: <br />2. Site ID.:Loc~ion: <br />Lab: Parameters: Description: <br />DisposttT to Grab/Compostte: <br />Sample Split: Comments: <br />Flow/Level: pF~- Temp. t er: <br />3. Site ID.: Location: <br />Lab: - 'a meters: escrtp ton: <br />Disposition: Grab/Composite: <br />Sample Split: Comments: <br />Flow/Level: pH: Temp. EC. Other: <br />4. Site ID.: Location: <br />Lab: Parameters: Description: <br />Disposition: Grab/Compostte: <br />Sample Split: Comments: <br />Flow/Level: ~ Temp. EC. Other: <br />5. Site ID.: Location: <br />Lab: Parameters: Description: <br />Disposition: Grab/Composite: <br />Sample Split: omments: <br />Flow/Level: pH: Temp. EC. Other: <br />CHAIN OF CUSTODY <br />1. Transferred from: To: Time/Date: <br />1. Transferred from: To: Time/Date: <br />1. Transferred from: To: Time/Date: <br />1. Transferred from: To: Time/Date: <br />Received at Lab by: Date: <br />4/85 Doc. 8934E <br />