2010-09-29_REVISION - M1981185 ‎(11)‎

• Permit No: M1981185
• IBM Index Class Name: REVISION
• Doc Date: 9/29/2010
• Doc Name: Conversion Application for a 112‎(d)‎ Permit Part 2 Exhibit I Attachment 2 thru S
• From: Wildcat Mining, Co.
• To: DRMS
• Type & Sequence: CN1
• Email Name: WHE
• Media Type: D
• Archive: No

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Contact: p,?,Cw KAY I-
Address:
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Phone Number: Lmz) 33?-q•66y
FAX Number.
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CHAIN OF CUSTODY RECORD
NOTES:
1) Ensure proper container packaging.
2) Ship samples promptly following collection.
3) Designate Sample Reject Disposition.
PO#
•
Page of
Table 1. - Matrix Type FOR GAL USE ONLY
1 = Surface Water, 2 = Ground Water GAL JOB #
3 = Soil/Sediment, 4 = Rinsate, 5 = Oil 1005'
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6 = Waste, 7 = Other (Specify) lloeu
Project Name: Ott-oc ?li.T t" A"t tx* Samplers Signature:
Lab Name: Green Analytical Laboratories [phone] FAX [phone] An alys es R equired
Address: 75 Suttle Street, Durango, CO 81303
Collec tion Miscellaneous Preservative(s)

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Relinquished by Date: Zd a Time: Received b f. Date +!6 Time: O
Relinquished by: Date: Time: Received by: Date: Time:

* Sample Reject: [ ] Return ( ) Dispdse [ ] Store (30 Days)