GENERAL51985

• Permit No: C1981048
• IBM Index Class Name: General Documents
• Doc Name: MONITORING FACT SHEET LABORATORY SAMPLES
• Permit Index Doc Type: RECLAMATION PROJECTS
• Media Type: D
• Archive: No

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Page 1 of L
MINED LAND RECLAMATION DIVISION
MONITORING FACT SHEET
~-~• ^ ,,LABORATORY SAMPLES
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Company/Address: M Co .U. (j S ~ ~ Sioj S Mine Contact:
Specialist: ~,~,~
Date: al Time: ~;~G ~,,,,,, Weather: (~,rr,,~ ,r
Comments : r aboratory . ~ (-~~ny,,~f
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1. Site ID.:~/ Location:'
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Full Ground Water/Full Surface Water/Partial Sample Gleo /Soil/Grab Composite/~iltered/Raw
Disposition:-Tc,~p ;r.Jc n,~ls In.Y,J .,~ +1,FcQ ro (P -~c~ ~7laz a..+, Time: ~~; 3n
Sample Split: UQ~Comments: Ita,,.Pos;~c Sw,yp~' Slac~~~pl;-k-Fc.-k.,.. l~y~(~
Flow/Level: pH: Temp. ]iC. Others. v
2. 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:
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: pH: Temp. E:C. Other:
4. Site ID.: Location:
Full Ground 4later/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw
Disposition: Time:
Sample Split: Comments:
Flow/Level: pH: Temp. EC. Other:
5. Site ID.: Location:
Full Ground Water/Full Surface Wa[er/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw
Disposition: Time:
Sample Split: Comments:
Flow/Level: pH:
Temp. EC.
Other:
CHAIN OF CUSTODY
1. Transferred fro '..,o To: Time/Date: 2~`js n/ iz~4`~
1. Transferred f m: To: Time//DateJ: Zy~y~ 09~Do
Received at Lab by:~~,Q,p~.,,ppy-~ Da[e: OZ.(Z3 l~s
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