2012-07-12_GENERAL DOCUMENTS - C1981008 ‎(3)‎

• Permit No: C1981008
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 7/12/2012
• Doc Name: Soils Data from OSM
• From: Rick Williamson- OSM
• To: Chris Kamper
• Permit Index Doc Type: General Correspondence
• Email Name: DAB
• Email Name: MLT
• Email Name: SB1
• Media Type: D
• Archive: No

Company Name:
Office of Surface Mining
Project Name, PWS, Permit, Etc.
New Horizon Mine
Sample Origin
State; CO
EPA/State Compliance:
Yes ❑ No
Report Mail Address: 1999 Broadway, Suite 3320
Denver, Co 80202
Contact Name: Phone /Fax: Email:
303 - 293 -5040 am re or osmre. ov
Amy McGregor g g
Sampler: (Please Print)
Key Ag
Invoice Address: 1999 Broadway, Suite 3320
Denver, CO 80202
Invoice Contact & Phone:
Colleen Zaremba 303 - 293 -5045
Purchase Order.
Quote/Bottle Order
Special Report/Formats — ELI must be notified
prior to sample submittal for the following:
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Contact ELI prior to
RUSH sample subm i t t a l
tor charges and
scheduling — See
Instruction Page
Shipped by
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Cooler IOW:
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❑GSA ❑ EDOIEDT(Eteetronic Dalai
Comments:
-ID # 2xxxx
- Sample Interval In
feet; example 15 -20
p
- Sample location
Al , 01 etc..
Receipt Temp
1 V ° C
p POTWrnrWTt� Format:
On ice: �I
Yes No
❑ State: 0 LEVEL IV
❑ Other: ❑ NELAC
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custody $eat Y lJ
Intact Y N
Stemmer*
atch Y a N
SAMPLE t0ENTiFICATtON
(N ame, Location Interval etc.
ID # 21705, 131, 35-40
Collection
Date
Collection
Time
MATRIX
1 -Soi1
X
X
X1112C416351
ID # 21802, 82, 20-25
1 -Soil
X
X
,r\
a ID # 21803, 82, 25-30
1 -Soli
X
X
X
ii,M
ID # 21807,133, 0-5
1 -Snit
X
X
X
ID # 21808, 03, 5 -10
1 -Soil
X
X
X+
6 ID # 21904, 83, 35-40
1-Soit
X
r
X
R
ID # 21908,134, 10 -15
1 -Soil
X
X
X
1 ID # 22007, 85, 5-10
1 -Soil
X
X
X
ID # 22010, 85, 20-25
1-Soil
X
X
X
° ID # 22102, 65, 30-35
1 -Soil
X
X
X
i
Custody
Record
MUST be
Signed
Rewwniyned by (pint): Dateffinw sa�nanue
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ttecemd by (v4k DelefThte. /alma:
�ncl by (Print): stare:
Received by gent): oetenene: Signature
Sample Disposal: Return to Client: Lab Disposal: <G'IP
t'�°� b y t.aearat o`aw / r+ne: /'��
i .C�! /'?,� 2 G1.- -� 2- 9 ! �t l�
Chain of Custody and Analytical Request Record
PLEASE PRINT- Provide as much Information as possible.
Page L
in certain circumstances, samples submitted to Energy Laboratories, Inc. may be subcontracted to other certified laboratories in order to complete the analysis requested.
This serves as notice cif this possibility. All sub contract data wilt be clearly notated on your analytical report.
Visit our web site at www.eslergvlab cgm for additional information, downloadable fee schedule. forms, and links.