ENFORCE37030

• Permit No: C1981010
• IBM Index Class Name: Enforcement
• Doc Date: 3/27/1998
• Doc Name: SAMPLE RECEIPT FORM
• Violation No.: CV1998003
• Media Type: D
• Archive: No

Page ' o~~ '
MINED LAND RECLAMATION DIVISION
MONITORING FACT SHEET
LABORATORY SAMPLES
Operation:
Company/Ad
Special2i~s~t~
Date r
Comments:
1. Site
Full Cround Water/
Disposition:
Sample Split: > Comments:_~/~1 /
Flow/Level: 1 t/ pH:~Temp.~~E
Site ID.: Np /~,!",~M.Q Location:_~
Full Ground Water/9Full Surface Water artial Sampl
Disposition• CQ7~PN ~- ? r~
2
File ~k: ~ w/~D/D
Mine Contact:
Sample Split:Comments:~~AZaJ11~C2SfJY~1.c~UM..C dH.d~/Y11J0.,~'CN: 5$~ '~'.SO
Flow/Level: N Q pH:LuT Temp.~/~EC. r1(T Other:
Site ID.: Location:
Full Ground Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw
Disposition: Time:
Sample Split: Comments:
Flow/Level: pH: Temp. EC. Other:
Site ID.: Location:
Full Ground 4later/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw
Disposition: Time:
3
4
Sample Split:
Flow/Level:
5. Site ID.:
Comments:
Temp. EC.
Location:
Composite/Filtered/Raw
Time: /7~QZ
Other:
Full Ground Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw
Disposition:_
Sample Split:
Comments:
Flow/Level: pN: Temp. EC. Other:
CHAIN OF CUSTODY
1. Transferred from: T~e~t/H"~s./-~ Time/Date:
1. Transferred from: To: Time/Date:
Received at Lab by:
Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw
Date:
3~
Time:
~v o9'ys-
8934F O O O Y R M O D Y A