REV09825

• Permit No: C1981048
• IBM Index Class Name: Revision
• Doc Date: 4/22/1992
• Doc Name: MLRD MONITORING FACT SHEET LABORATORY SAMPLES
• Type & Sequence: TR9
• Media Type: D
• Archive: No

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MINED LAND RECLAMATION DIVISION
MONITORING FACT SHEET
LABORATORY f~AMPLES
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Specialist: ;
Date: '-
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1. Site ID.: ~'~ ' ' r y is ~, Location:
Full Ground Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw '
Disposition: ~ ~ ~ - Time: ,`~ 9e
Sample Split: A. Comments:
Flow/Level: pH:~% Temp. EC.~ Other:
2. Site ID.: ~ ~ Location:
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Full Ground Water/Full_Surf ace Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw
Disposition: Time: )?
Sample Split: ~ Comments:
Flow/Level: pH: Temp. EC. ~ Other: i
3. Site ID.: ~ ~ Location:
Full Ground Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw.
Disposition: „ Time: ;;
Sample Split: Comments:
Flow/Level: j ~ ~~ pH; ~ Temp. EC. ~ Other:
4. Site ID.: ~ •4-"~ r Location• -
Full Ground 4later/Full Su~~c_e._Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw
Disposition: ~ Time: !,
Sample Split: Comments:
Flow/Level: pH:" Temp. EC. Other:
5. Site ID.: Location: i
~ Full Ground Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw
i
Disposition: Time:
~I Sample Split: Comments:
Flow/Level: pH: Temp. EC. Other:
CHAIN OF CUSTODY
1. Transferred from: r` To: Time/Date: M.. ~~ /'„
1. Transferred from: To: Time(Date:
Received at Lab by: Date:
8934F 000YRMODYA