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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
<br />Report Mail Address: 19913 Broadway, state 3320
<br />Denver. CO 80202
<br />Contact Name: Phone/Fax: Email:
<br />Amy McGregor 303- 293 -5040 amcgregor @osmre.gov
<br />Sampler: (Please Print)
<br />Key Ag
<br />invoice Address: 1999 Broadway, SuIle 3320
<br />Denver, CO 80202
<br />Invoice Contact & Phone:
<br />Colleen Zaremba 303- 293 -5045
<br />Purchase Order.
<br />Quote /Bottle Order:
<br />Special Report/Formats — ELI must be notified
<br />prior to sample submittal for the following:
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<br />H-Sample
<br />Contact ELI prior to
<br />RUSH sample submittal
<br />Shipped by
<br />Key Ag . ii
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<br />for charges and
<br />scheduling — See
<br />Instruction Page
<br />crater tofelc
<br />�V
<br />❑ DW • A2LA
<br />❑ GSA ❑ EDD /EDT(Electronic Data)
<br />Comments:
<br />-!D # 2xxxx
<br />- Sample Interval in
<br />f ee t ; example 15 -20
<br />location
<br />Al, 61 etc..
<br />Receipt Temp
<br />1
<br />J -s' 6 ° C
<br />❑ POTWlWWTP Format:
<br />On Ice:
<br />Yes No
<br />❑ State: ■LEVEL 1V
<br />El Other: ❑ NELAC
<br />Custody Seat Y N
<br />Intact Y
<br />signature Y
<br />N
<br />match
<br />SAMPLE IDENTIFICATION
<br />(Name, Location, Interval, etc.)
<br />Collection
<br />Date
<br />Collection
<br />Time
<br />MATRIX
<br />t ID # 22504, 810, 20-25
<br />1-Soll
<br />X
<br />X
<br />X
<br />41 1 abyC3S
<br />ID # 22509, C1, 5-10
<br />1 -Soil
<br />T
<br />T
<br />ID # 22510, C1, 10-15
<br />1 -Soil
<br />X
<br />EMI
<br />X
<br />Mila
<br />ID # 22604, C2, 5 -10
<br />1 -Soil
<br />0111111111111111111111111101111
<br />ID # 22604, C2, 5 -10
<br />�s r i-c,e
<br />hilt
<br />1.1 -Soil
<br />a ID # 22702, C3, 15-17
<br />1 -Soil
<br />X
<br />ME
<br />X
<br />7
<br />ID # 22707, C4, 20 -22.5
<br />1 -Soil
<br />X NMI
<br />X
<br />��■
<br />ID # 22708, C5, 0-5
<br />1 -Soil
<br />X
<br />ID # 22709, C5, 5-10
<br />1 -Soil
<br />X
<br />X
<br />Q=
<br />"' ID # 22807, C6, 20 -23
<br />1 -Soil
<br />X
<br />N ; egnqubhed • y (pont): .:
<br />Custody X • r, Ay gi 4 y/� 2 :3Cp -,
<br />a tee:
<br />. eceive • br (p r.
<br />, •, : ens: SIgnatute
<br />? a .," --�.
<br />Record Regraaletted by tprMt ; telrfine• Signature: Received by (prinII: Oate/rane: Signature
<br />MUST be -
<br />Signed tved Uborst Dal nei, / L � -
<br />Sande Disposal: Return to Client: — Lab Disposal: / _S,F �'1P,►�/ / bd K " C 4% I i ea
<br />Chain of Custody and Analytical Request Record
<br />- P rovide as much Information as possible.
<br />Page 4 or
<br />In certain circumstances, samples submitted to Energy Laboratories, Inc. may be subcontracted to other certified laboratories in order to complete the analysis requested.
<br />This serves as notice of this possibility. All sub - contract data wifl be clearly notated on your analytical report.
<br />Visit our web site at www,eneravlab.com for additional information, downioadable fee schedule, forms, and links.
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