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FH-Central Plateau Project CHAIN OF CUSTODY/SAMPLE ANALYSIS REQUEST F"6-62 I Page 1 of 1<br />

Collector<br />

Johansen/Pop e/P6ster<br />

Project Designation<br />

200-PW-2 /200-PW4 OU - B orehole Soil Sampling<br />

Ice Chest No. C^-p L OS<br />

/C<br />

Shipped To fztzx 0f<br />

POSSIBLE SAMPLE HAZARDS/RE<br />

Special Handling and/or Storage<br />

22 c<br />

SAMPLE ANALYSIS<br />

Company Contact Telephone No.<br />

LC Hulstram 373-3928<br />

Sampling Location<br />

216-A-37 (C4106); (12.5'-157<br />

Field Logbook No.<br />

HNF-N-3361<br />

COA<br />

117504ESIO<br />

OEM Property No. ^y .O<br />

24 V<br />

Preservation<br />

Type of Container<br />

No. of Con ta iner(s)<br />

Volume<br />

Sample No. Matrix • Sample Date Sample Time<br />

B16W79 SOIL & G3<br />

P ro ject Coordinator<br />

TRENT, Sl Price Code $N Data Turnarouo<br />

SAF No.<br />

F03-006<br />

Method of Shipment<br />

Federal Express<br />

COW 4C Cool 4C - cDat 4C rime Nmc<br />

aG<br />

aG aG aG a<br />

I I 1 I I<br />

120ml, 60WL 120ml, 60•l, 60mL<br />

Clumnim NOLNO3- ailaGnsse- ssitem(1)' Td -M<br />

Hex - 71% 3512 413.1 speeid<br />

Air Quality q<br />

Bill of Lading/Air Bill No. 0295 PC -<br />

N OF POSSESSION Sign/Print Names SPECIAL INSTRUCTIONS<br />

b7. s3<br />

Relinquished B ved Fro DatNCmte liar 2o ved B/Stored In<br />

R.<br />

r«^ I 37q2-0<br />

DaWTimeu<br />

^<br />

L l Z8o3 1 6 / 5<br />

^.3 . f 4 r<br />

mpon both Iwasene and diesel range compounds fran W1PH-D analysts.<br />

•• The labommry ism<br />

Relmq ' ed By/Rctmved Fm Da&T— f )<br />

oo Received By/Stored N Daterime th (Ij-i'ccMire.m 09 °- °990 T mI Sr fzaroo Tbori<br />

8tZ OJ<br />

(Thl ' +a^ . r.^.__ r.._ _<br />

elinquished By ved FAmm /^^/t ^ Dat&T=<br />

Sic j E l daQa 10 Recdved By/Sum:d D&VUTime<br />

F — x<br />

di q By<br />

t{f<br />

ved From Dardfime<br />

S t 6 3 0,7<br />

Recd In Dmd['ime<br />

LJ-03 01 Y,<br />

Relinquished By/Removed F•tan Duelfime Received By/ In Dat.Tunc<br />

Relinquished By/Removed From Daterr me Received By/Stored In DausTime<br />

a\v^\<br />

Personnel not available to<br />

relinquish samples onl the 3728<br />

Ref # .L^ on<br />

1-1--IQ3<br />

LABORATORY R-rived By - Title Date/fime<br />

SECTION<br />

FINAL SAMPLE Disposal Method Dispmed By DatcTime<br />

DISPOSITION<br />

SHI-EE-011 (03101/2002)<br />

45 Days<br />

Ma tr ix<br />

s-Sau<br />

sE d s.es<br />

ro-sau<br />

n-suaF<br />

oDu<br />

DL,V.Lalr b<br />

DI' Drvm Lipii4s<br />

w w,<br />

uw^<br />

v-v pw^..<br />

X.<br />

i

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