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+! ;~~; • • Pa III I II I II I II IIII III <br />Operation: <br />Company/Ad <br />Special/i/s,t <br />Date r <br />Comments:' <br />~~ <br />File Ik: ~~(-~7l <br />Mine` Contact• ~/7„ j <br />1. Site ID.: p7(/(e~,~~~¢7~~~~ Location: ~.( - o,/ .fj'6C <br />Full Ground Water/Full Surf/ace Water/Partial Sample/Geo./ oil <br />Disposition: /~,;/~i (/~ <br />t~ /Filtered/Raw <br />J r~1 <br />Time : y'~ l~~~ !. <br />Sample Split:^// o Comments: ~v~f ~ 7yUr7 -1 cl~f[r~~~//, ,j Q~C~s <br />Flow/Level: pH: Temp. EC. Other: <br />2. Site ID.: Location: <br />Full Ground Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw <br />Disposition: Time: <br />Sample Split: Comments: <br />Flow/Level: pH: Temp. EC. Other: <br />3. Site ID.: Location: <br />Full Ground Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw <br />Disposition: Time: <br />Sample Split: Comments: <br />Flow/Level: pH: Temp. EC. Other: <br />4. Site ID.: Location: <br />Full Ground 4Ia[er/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw <br />Disposition: Time: <br />5 <br />Sample Split: Comments: <br />Flow/Level: pH: Temp. EC. Other: <br />Site ID.: Location: <br />Full Ground Water/Full Surface Water/Partial Sample/Geo./Soil/Grab/Composite/Filtered/Raw <br />Disposition: Time: <br />Sample Split: Comments: <br />Flow/Level: pH: Temp. EC. Other: <br />CHAIN OF CUSTODY <br />1. Transferred from: <br />1. Transferred from: <br />Received at Lab by: <br />To: Time/Date: <br />To: Time/Date: <br />Date: <br />8934F OOOYRMODYA <br />MINED LAND RECLAMATION DIVISION <br />MONITORING FACT SHEET <br />LABORATORY SAMPLES <br />