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Company Name: <br />Office of Surface Mining <br />Project Name, PWS, Permit, Etc. <br />New horizon Mine <br />Sample Origin <br />State: CO <br />EPA/State Compliance: <br />Yes • _ No VI <br />Report Mall Address: 1999 Broadway, Suite 3320 <br />Denver, Co 80202 <br />Contact Name: Phone/Fax: Email: <br />Am McGregor 303 - 293 -5040 amcgregor @osmre.gov <br />Y <br />Sampler: (Please Print) <br />Key Ag <br />Invoice Address: 1999 Broadway, Suite 3320 <br />Denver, CO 90202 <br />Invoice Contact & Phone: <br />Colleen Zaremba 303 - 293 -5045 <br />Purchase Order. <br />Quote/Bottle Order: <br />Special Re ort/Formats - ELI must be notified <br />t� P <br />prior to sam <br />sample submittal for the following: <br />p 9 <br />❑ DW A A2LA <br />❑ GSA EDD /EDT(Eiectronic Data) <br />❑ POTWMMITP Format: <br />G1trVJl�l! 1( 1 ;3�.a(��i�jl�i`tlt,l��) <br />Contact ELI prior t o Shipped by <br />Key Ag / <br />RUSH sample submittal y g ,(4, <br />o <br />m m <br />>' l Q <br />p <br />1 a = 1 <br />ja 0 i <br />S I a <br />� m o <br />3 Q <br />= '` <br />a A i g a ` w la <br />a eL w (0 , <br />z <br />R for charges and Cooler tots : <br />scheduling - See A y <br />Instruction Page I V <br />u <br />Comments: R.oetptTemp o <br />LS r� C <br />-ID # 2xxxx <br />° - Sample Interval in (Inks <br />feet; example 15 -20 Yes N <br />❑ State: ■ LEVEL IV <br />Other: <br />❑ ❑ NELAC <br />H - Sample location cust s„1 Y0 <br />Al, B1 etc.. Intact Y N <br />Signature Y N <br />Match <br />SAMPLE IDENTIFICATION <br />Name, Location, interval etc. <br />Collection <br />Date <br />Collection <br />Time <br />MATRIX g g <br />1 ID # 21009, A2, 15-20 <br />1-49o11 X X ■.,■■■■1 X <br />IaO41r0S7 <br />2 ID # 21010, A2, 20 -21.5 <br />1 -Soil 11 I X <br />1 -Soil ,�(` <br />X <br />ID # 21106, A4, 0 -5 <br />1 -Soil X X ■■■■■■ X <br />1 -Sal rde <br />1 -Soli OM III ■■■■ X <br />- � <br />Ka II I _ <br />` ID # 21202, A5, 0 -5 <br />5 ID # 21310, A7, 15-20 <br />111111111_ <br />e ID # 21403, A7, 30-35 <br />e ID # 21404, A7, 35 -36.5 <br />1 -Soil On <br />-' <br />ID # 21408, AB, 15-20 <br />1 -Soli DO■ III ■■ ■■■. X <br />OM II III <br />9 ID # 21501, A8, 30 -35 <br />1 -Soli X X ■r■■■■■■ X <br />1 0 ID # 21510, A10, 0 -5 <br />1 -Soil X X X <br />Chain of Custody and Analytical Request Record <br />Custody 6 ;1 shed 'y �`l' <br />Record � <br />MUST be <br />Signed <br />Sa 1: Return to Client: <br />VIZ, het 1. 2 LtpnM rn <br />Daleme: <br />PLEASE PRINT Provide as much information as possible. <br />by 1PI <br />: <br />Mg:velure: <br />fWU <br />r <br />Lab Disc •s81: <br />Received by (Plitt): <br />Datef me: <br />by <br />4t <br />Page 1 of 5 <br />Signature: <br />In certain circumstances, samples submitted to Energy Laboratories, Inc. may be subcontracted to other certified laboratories in •rder • complete the analysis requested. <br />This serves as notice of this possibility. All sub data will be clearly notated on your analytical report. <br />Visit our web site at www.eneravlab.com for additional information. downloadable fee schedule, forms, and (inks. <br />