2012-08-28_REPORT - M1989120

• Permit No: M1989120
• IBM Index Class Name: REPORT
• Doc Date: 8/28/2012
• From: Aggregate Industries
• To: DRMS
• Permit Index Doc Type: Annual Fee/Report
• Email Name: PSH
• Media Type: D
• Archive: No

A 17
Company Name /Address
Alternate Billing
Time.
Analysis/Container
Samples returned via: FedEx UPS _Other_
Cogdilit�i _ (lab use gldy)
/Preservative
t(05 0
AV4f Chain of Custody
Relinquisher by(Signature
Date
Page_of_
Received by: (Signature)
-
_
Molen & Associates, LLC
Date
Time
Received -for 10 by: (Signature)
Date: °
Tana: '• _
pH Ch4O
CV)
t1
-
Prepared by:
2090 East 104th Ave Suite 205
z
Thorton. CO 80223
3
a.
ENVIRONMENTAL
w
-
Science Corp
p
X
N
0-
_
12065 Lebanon Road
Report to, Mark Molen
C3
o
U3
o
Z
w
• N
y
a
Mt. Juliet TN 37122
E-mail to molenassociates @ gmall.com
Project Description. Broda All Inert Fill
p
_
=
°
w
a
a
Phone [phone]
Phone [phone]
PHONE. [phone]
Client Project No. 10 -0133
Lab Project #
p
FAX [phone]
FAX [phone]
a.
'
Y
Q
N
2
Z
O
Coll e{I by \
SitelFacility ID# Brod■ Al
P.0 P• #
'�
L�.
+
w
m
W
ai
o
fV
v
CbCode - flab use only]
_
M ` "ENTCO
Collected by(signature)
Rush? (Lab MUST be Notified)
Date Results Needed
No
Same Day ....... 200%
V
U
_ a
Twiplat
="
Next Day........ 100%
of
Y
m
_
Z
(L
OL
Email ?_No_Yes
Two Day.....
FAX?—No—Yes
Z
m
m
O
'
Shipped-Via: Denvt3i`9�ce Cen"tT4, -
Packed on Ice N_ Y
..50%
U
-
L)
�
N
00
_
p
Sample ID
Comp /Grab
Matrix
Depth
Date
Time
^,ntrs
Remarks/contaminant ontaminant
Sample # (lab only)
MW -1
Grab
gw
7 IZ-,(/
8
X
X
X
X
X
X
MW -2
Grab
gw
�%
tow
8
X
X
x
X
-X
X
MW-3
Grab
gw
8
X
X
-
X
"-
X
'"
l�
env-= _
-
--
Matrix: SS- Soil /Solid GW- Groundwater WW- Wastewater DW- Drinking Water OT-Other.
Remarks:
y pH Temp
Q 4 k #- r/ 3'i zvjz•o Flow Other
b (Si
at
Time.
Received by.(Signature)
Samples returned via: FedEx UPS _Other_
Cogdilit�i _ (lab use gldy)
Rinuisher
t(05 0
Terrlp;
Relinquisher by(Signature
Date
Time.
Received by: (Signature)
-
Relinquisher by:(Signature
Date
Time
Received -for 10 by: (Signature)
Date: °
Tana: '• _
pH Ch4O