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HomeMy WebLinkAboutCreekside (3) (., CERTIFICATION OF EXEMPTION
—Y
/ FROM REQUIRING A CAMA PERMIT
\ / as authorized by the State of North Carolina,
0 Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCACi Subchapter 7K .0203.
licant Name e l(J t kSi A ( yC1(..k4 L.t U b CO "It rrn14 Y&Mkt Phone Number - I0, 3 5b.01
ress IS L 011 fl.ey' tr.
State t. (_, Zip ,aSti
ect Locatio (County, State Road, Water Body, etc.) 6tn1 p tarn Y Cnurrk-)1 US V1WY } ) 633y
l, - by' + -h �''ti:=,1li ►, , C Vv -V...
e and Dimensions of Project Ex to v -1-f C ti �'A r tt rvd-rd 40 t L- --Pvt rn 1 CZ 4
' tl ;�uri t ki.ti ,trtu Lir(il16Cii( fit II/ ,
1
proposed project to be located and constructed as described This certification of exemption from requiring a CAMA pc
ie is hereby certified as exempt from the CAMA permit re- valid for 90 days from the date of issuance. Following ex pi
ament pursuant to 15 NCAC 7K .0203. This exemption to a re-examination of the project and project site may be nec
IA permit requirements does not alleviate the necessity of to continue this certification.
obtaining any other State, Federal,or Local authorization.
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12/29/2008 15:26 19197330059 PERCS PAGE 01/
vie: ev t'n www. nre. UScp. ni] Artn' Page 1 nr 3 litCL09Z0
NATIONAL RESPONSE CENTER 1-000-424-8802
***GOVERNMENT USE ONLY***GOVERNMENT USE ONLY***
Information released to a third party ehall comply with any
applicable federal and/or state Freedom of Information and Privacy Laws
Incident Report # 893574
INCIDENT DESCRIPTION
'Report taken by; CIV ANTONAY GREER at 14: 22 on 29-DEC-08
Incident Type; PIPELINE
Incident Cause: UNKNOWN
Affected Area: BRAOLEY CREEK
Incident was discovered on 29-DEC-08 at 13: 45 local Incident time.
Affected Medium: WATER /PRADLEY CREEK
REPORTING PARTY
Name: THOMAS VAN
Organization: CREEK SIDE YACHT CLUB
Address: 6334 OLEANDER DR.
WILMINGTON, NC 28403
CREEK SIDE YACHT CLUB reported for the responsible party.
PRIMARY Phone: (910) 3500023
Type of Organization: PRIVATE ENTERPRISE
SUSPECTED RESPONSIBLE PARTY
Name: THOMAS VAN
Organization: CREEK SIDE YACHT CLUB
Address: 8334 OLEANDER OR.
WILMINGTON, NC 28403
PRIMARY Phone: (910) 3500023
INCIDENT LOCATION
6334 OLEANDER OR. County: NEW HANOVER
City: WILMINGTON State: NC Zip: 28403
RELEASED MATERIAL (S)
CHRIS Code: GAS Official Material Name; GASOLINE: AUTOMOTIVE (UNLEADED)
Also Known As:
Qty Released: 0 UNKNOWN AMOUNT City in Water: 0 UNKNOWN AMOUNT
DESCRIPTION OF INCIDENT
CALLER IS REPORTING THAT GASOLINE IS RELEASING FROM A UNDERGROUND
GAS LINE. THE CAUSE OF THE LEAK I5 UNKNOWN AT THIS TIME.
SENSITIVE INFORMATION
INCIDENT DETAILS
Pipeline Type; SERVICE
DOT Regulated: UNKNOWN
D�....Y ..... A.-..� ir..1 .... n.. ,ter. ....... �
12/29/2008 15:26 19197330059 PERCS PAGE 02/
ig.CV,Via UC: Xy rn www. nrc. uccp. ■i.1 Attn: Page 2 at 5 *zZ2920
---WATER INFORMATION---
Body of Water: BRADLEY CREEK
Tributary of: ICW
Nearest River Mile Marker;
Water Supply Contaminated: UNKNOWN
IMPACT
Fire Involved: NO Fire Extinguished: UNKNOWN
INJURIES: NO Hospitalized: Empl/Crew: Passenger:
FATALITIES: ND Empi/Crew: Passenger: Occupant:
EVACUATIONS: ND Who Evacuated: Radius/Area;
Damages: NO
Hours Direction of
Closure Type Description of Closure Closed Closure
N
Air:
N Major
Road! Artery: N
N
Waterway:
N
Track:
Environmental Impact: NO
Media Interest: NONE Community Impact due to Material:
REMEDIAL ACTIONS
BOOMS APPLIED, ABSORBENTS APPLIED
Release Secured: YES
Release Rate!
Estimated Release Duration:
WEATHER
Weather: OVERCAST, h�F
ADDITIONAL AGENCIES NOTIFIED
Federal: USCG
State/Local: NONE
State/Local On Scene: FIRE DEPT.
State Agency Number: NO REPORT #
NOTIFICATIONS BY NRC
USCG HSOC AT OHS (USCG HSOC DESK)
29-DEC-08 14: 29 (202)2828114
USCG ICC (ICC ONI)
29-DEC-08 14; 29 (301)6593363
DOT CRISIS MANAGEMENT CENTER (MAIN OFFICE)
29-DEC-08 14: 29 (202) 3661883
U. S. EPA IV (NC/SC INCIDENTS)
29-DEC-08 14: 29 (404) 6504955
U. S. EPA IV (DUTY OSC)
(404)5504955
; 12/29/2008 15:26 19197330059 PERCS PAGE 03/
ad/CH/pH 02: 2? PH www. nrc. usrg. mil Attu? Page 3 of 3 #2259ZO
PIPELINE & MAZMAT SAFETY ADMIN (OFFICE OF PIPELINE SAFETY (AUTO) )
29-DEC-08 14; 29 (202) 5650568
SECTOR NORTH CAROLINA (COMMAND CENTER)
(252) ^e474570
STATE OF NORTH CAROLINA DENR (MAIN OFFICE)
29-0EC-08 14; 29 (819) 7335083
ADDITIONAL INFORMATION
CALLER HAD NO ADDITIONAL INFORMATION.
*** ENO INCIDENT REPORT *893574 ***
Report any problems by ca1JJng 1-800-424-8802
PLEASE VISIT OUR WEB SITE AT http; //www, nrc, uscg, mil
P.
TRANSACTION REPORT
DEC-29-2008 MON 02:3
FOR: NCDENR 910 350 2004
RECEIVE
DATE START SENDER RX TIME PAGES TYPE NOTE M#
)EC-29 02:31 PM 19197330059 53" 3 FAX RX OK
I(*********************************************** ****K**************************K******)i
1
. aa, au,mwn..�n.c
P , ,,, i his torm shQald na comploted and aubmlirea to the UST Section's regional office following a known or saspacWd release from
an underground s:,t .r tank(UST)system, T^.Is form IS required lc be stlovlrted within 24 hours of dlseavery of a anawn cr
P art NC suspected release >.�. ... _.�
(DMA USE ONLY Suspected Contamination^ (YJN) y 1 Facility ID Number
rctoent4 Risk(H,I,L,L:)_ Co-tinned GW Contamination?(YIN) Date Leak Discoverer! .
Received On Receded By Corif'rtned Soli Contamination':(`r'iN) I Comm/Non—Commercials -_
P.e®crted bk./ (ciro?e ere):Phone.Fax or Report Samples Take i?(Y?N) Reg/Nutt•reguiaied'
Reoton Free Product?(YIN) if Yes.Stale Greater:
—H...............,_ Thickness _ _.___._.
i
INCIDENT DE CRIP/TI
R Incident Mama. ' t I'''.Z-1-)�
noress. U—e..- ty_ 1 R®gGnai Cnc6( rcre one• Ash idle,(dlooresiAis.�'ayette ripe,
d Ci ,�,t„(Fon: ZIP Code:c,2 Raleigh.Washington, on, maton•Salem
$ Latitude(aacI eigrees). Longitude(escr rearm!. 1 Obtuired by:
pBriefly describe suspected or confirrriec release:(indudi,ig but not tinkled tC:nature of release,dated release,amount I j Gps
Et of mfease,,arnount of free pioduct esorr anti cecn�✓/sflnefts,!ntt'al ra/rses cond tt .eo.impacts to receptors) s
OA/ '<7 / v�©_ t �5-e 4cr--- r .$/ff�T�/C-- p ographic mac
s ;I 1 3 Gal Address matching
v_ Cl Other
¢/s. �o_s,,e..cls .
jD Unknown
r 1 - Describe Iocatioli:
HOW RELEASE W DISCOVERED 4R41e4So Code)
(Criecit one)
F
i Release psiectlon k-ufpm ert or tvierhos A VlaualiOcIor :� Groundwater Contamination
Luring UST CloruteiRsmoval 3 ,Jatau In Tank 0 Surface•.Vatar ontarunaban
Property i-smiler Water St ply We Gon aminetian a Other(specify; --------
SOURCE OF CONTAMINATION
source of Reies Cause of Release of i�z.i��� r #t,ct Type sieaseu
,,,-;heck one to rind cite primary (Gnecic one to irtdIcafe p.^mary Chee anvi (Check one to indeaafe primary product type
sctrl`sl cause) released)
(
L Tana spillP9tr916�m �Gasolln Diesolr DlaSet eG.^I
_ Kerosene £lend
�Irfn:r '.-..1Oven l' Non Pe rolat m ID Heating 01 r . ✓egetakte Oil t U4°,•
'.,d CIapenaer V Corrosion J Butt7the-Patroleuro 0 Etp-E2�
•j Submersible T ine PI.mp 1LII Physical o-Ivlechar cal Proruc�
Damage Location Metn i E•1 -E@4
..-3 Vetiver';Prob.arr
0 Install Prahlem r (C+lscx one) U Iiher limier-lies rganiea .e EFtf-Eye
. Caftan i D Other Organics Z Elhancl tYJ%
thef a �Ot F3ciflyc} K.ri,_. -
a,.rimiown c /w tot - o4
Unknown U ftestdene
1740 1:?.rl:,7rB5r-t t 2o.1 eI-4tS/.7 o-i`o on .,,=rs0 a C3 other
o
alunicip4i 2. hlih:ary 3. UnKnor.n 4. Pnva'.' S.Federal B. :oW .nty ti=
- .�
i r,7,7ebretio t TIPP
11U1 1 1 ;bt.,. HP. NI,11LNK Hitc NU. :-.11 J .','30 c'.I.)l,L11 h-..
i --—
VI PAC14 OPONKING IAN#1 ER SUPP'JES 1
'J, I
1Aits-O0 Supply Aiells Affth;tott? 1. Yes
! —
li tNvribef of INetar Supply Weis Affectoo
1, Water Supply Weirs Conlainirlatecl: (inchie User$Name ,Addresses and Phone iViopbers.Attach additional 513£18I if necessary) 1
F ' 1
•:
•
04 UST SYS7EM OWNER
•,,,c;--Owner/Comper.y A, : 1
..-_ _ _
Potri n•Contact 2 1 ss .....3. 4., 41,%.,,a,..i,.......4„, .. .. „...„.,
ar—v 15,3, t ,,
, ,::;, zlr.3CPZie Vc. i T04001'18 Nurn0'
' eir j
_
1 UST SYSTEM, OPERATOR
operato1:3pmeny : ActireAs
_.---
1--
,
: 7-cimp,3r,one Nitrit4ir
•r L ANDOW NER AT LOCATION OF UST iNCIDEN7
----- ,
----- 2-,."-?,-7' --------- slate .. I Zip Cone i i elepttone'lumber
Jraw 4ket0 Area (showing twa_craj91-__LT-a,,,__-' ini'er.4,, c,:ti ot::Atiz.Eh
1!---- -._.-.1=----1----- — '' :' ...
p,--- - -
IV arl- /3 r-.3-el/ ir•
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mmearcOomninnoo. .................. MIIIMILe.svemal Sueld .,
Toe ,....„ , ( ' fe ,' • r‘afP ..•
(E..2.-
2-3,1-F-07,61;02,08) Pe2e 2 1.1
Oittialtioni of Sew roes
Tank meunf ate tank Ow sumo the produet:414 is part of the widerg7ound sturagc tank system
Pi emg: IlliiallP the p:ping and connecters.wining from the'Atli:Ar nbrnersible turbine purnp to Eno dispemer ur other end-we-.:euipment(vera.,...;;:': ic:ovcry
ilnel Ur tote lusted)
Z...'soceser.me hides ill.dispenser and etc nquipment uSoa to connect-ilie lispchner to'.11v ising(c,r,„.1 rd Mae irrrt.1 suctiett pump or:tom 4:011110”CrltE loc,lati 4:-..vc
tht•:hear valve)
Fo., emible Ttotsire Pump:,STP)A lea in,iukieS the stihraersib:e turbine pump ite^art(tysiicany ii:i40.%c in the tank( rip) :!--v. line itc.k it:tail-Of.any he 1:ipla a:hot
k•OT,J).:10.9 the submetirhie iurbine pump us the tank
r.):!!kv,:ry F1.4,,l)!Cfr, ,din IfiaL teletents lila pi:cum:ft:Ittrinis product-dclivery:0 the tank, Typiaali a9USCS iita;j0:2L,in th t.a O.ftX aft spills and olerfila-1
3;T....--. sovce ps te 4.;131 to use wher the,-ocase sp.=is known tud moors ant fit ir..o one of rlic preced:ag ca...gorics(1.g.:foi ItiCase3['Mtn vent lines %a por
feenverN lines,and fill!Ines)
L n inc vrn .clantiiiti,re: es for..i.h ch the 1:01.1fee has rot beei.determined
Do'Ittlenrit of Cawies
Ssi'.l. i...::Lou cause wean 2 Mall occur ke_a„when.the dell ee,y hose ia disnunocaed from tat s.ink.fii papa or....hurt-lir norz.e o:-ernov,:n from:he dit,sscro.0
'i-v cr 11 j liar when on u0,11.1'.occurs(e.g..overt Ils ma/;natal front the fi!!tiipt w.the stink op.when 11=ntritcle tails to snui off st thu 4.14perucr;
P vsicil or'iiitchartira Dainag,e:use fer all types af riiysical or Illezhatigal dstnage:except corrosion Ce.6 r puncture ar.....nit cr pipit,: taot,e fnring,.1]rokan
citnix.w.)ta.ar.d temp.:Aunts Out;have:longed OnnensiOni
. .._... .............t.——,. ....1. -:-1-.. -..A.......-----,1..,,.....1,...,,...1,..t c.s eNsrn,I,N:II it 1:seol1e4 enenteiAn;Can;the frem if nisr;
ro l-r�.-cure 1-, r r oin:r;G i IU4G:7Z..Z i i i 1 0:`il.JYib 1 AO Y.�• t
. tea.
= LineiLD Test Data Sheet
_
PRFCI$I0N1:4,YKRf?7CE leIC
COMPANY Creekslde Yacht Club, Inc. TEST NUMBER 090105A-12
LucA1on, CREEKSIDE YACHT CLUB, INC. 'ST°ATE 1/5/2009
f ADDRESS 6334 OLEANDER DRIVE' I TECH NLCIAN I Howard Davis
crry/ STATE i WILMINGTON, NC CERTIFICATION 11433.LTN
LINE TEST
F Product Mid Grade 1 -�� I — —
SIP MFG Red Jacket __.._�
Isola i
tion C-Valve +--
Test Pressure 45 1
Initial Level .0825
Final Level .0825
Leak Rate .0000 -- —�
4 Start Time -- 10:30 - --- — -- ^,
End T,me 11:00 T-
Test Time 30
-I- 1 -,
Result Pass
• .LO TXST •� - .
^Ld ModeiTT FX1 V . i
Result Pass
LD Model
Result
- 1.
--- —._._
CumrrtnlS _..
1
I
1
Post Office Box 10279
Wilmington, North Carolina 28404-0279
CATLIN Telephone: (910)452-5861
Engineers and Scientists Fax: (910)452-7563
www.catlinusa.com
January 21, 2009
Creekside Yacht Club 3ksj " r
Attn: Tommy Vann
6334 Oleander Drive
Wilmington, North Carolina
Re: Creekside Yacht Club RECEIVED
Fuel Line Abandonment Soil Sampling
CATLIN Project No. 209-005 JAN 2 6 2009
Dear Mr. Vann: DCM 1NILMIYGTrr+J h,r..
CATLIN Engineers and Scientists (CATLIN) is pleased to present you with the
following letter report to document soil sampling at the Creekside Yacht Club (Site)
abandoned gas line and dispenser. The Site vicinity is illustrated on Figure 1 and the
Site layout including the former dispenser location is shown on Figure 2. Aerial
photographs obtained from MSN's "Bird's Eye View" online mapping are also attached.
Background
In general accordance with CATLIN Proposal 29004 dated January 7, 2009 and
subsequent work authorization, CATLIN personnel mobilized to the Site on January 8,
2009. The scope of work as proposed and agreed upon included soil sampling at the
former gasoline dispenser and along an abandoned supply line. Soil samples were to
be collected for total petroleum hydrocarbon (TPH) laboratory analysis.
According to personnel at the Site, the following information and actions were taken
prior to CATLIN's site visit and described to Ben Ashba on January 8, 2009.
o A sheen was noted on the water near the bulkhead at "Pump #3" on
December 29, 2008 (see attachments for dispenser/pump location).
o The underground storage tank system providing fuel to Pump #3 was turned
off and sorbent boom was placed in the water surrounding the sheen.
o The supply line was cut and a pressure fitting with an air line tap was added.
The supply line was pressurized to approximately 150 pounds per square
inch and then inspected.
o A small crack in the seam of the supply line pipe was discovered beneath
the former dispenser location.
o The leaking portion of pipe was cut off and caps were added to each end of
the abandoned supply line.
o Approximately 25 feet of abandoned supply line piping remains in the
ground.
o The supply line pipe is about one to two feet below land surface.
Methods
The former dispenser location and abandoned portion of fuel supply line were
identified. A hand auger boring was advanced at the end of the abandoned fuel line
and a soil sample was collected from approximately three (3) feet below land surface
(BLS). Hand auger boring photographs are attached. The hand auger was
decontaminated with phosphate free soap, pesticide grade isopropyl alcohol and
distilled water before boring advancement and soil sample collection.
A soil sample was collected by hand from the hand auger bucket while wearing new,
disposable nitrile gloves. Soil was packed directly into the appropriately labeled
glassware provided by the laboratory and placed on ice in an insulated cooler. The soil
sample was identified "Line (3)". The hand auger boring was backfilled with native
soils from boring advancement cuttings.
The hand auger was decontaminated as described above and a second hand auger
boring was advanced at the former pump/dispenser location (see attached
photographs). A soil sample was obtained following decontamination procedures and
sample collection methods as previously described. The soil sample was collected
from approximately two-and-a-half feet to three feet BLS and labeled "Dispenser (2.5-
3')".
Two (2) soil samples were transported by CATLIN and submitted to SGS
Environmental Services, Inc. (NC Certification #481) on January 8, 2009 following
proper chain of custody (COC) procedures. The soil samples were submitted for TPH
diesel and gasoline range organics (DRO and GRO) analysis per Method 8015 with
24-hour turnaround for results requested. The COC is attached following the complete
Results
Analytical results for DRO and GRO analysis are summarized on the table below and
the complete analytical report is attached.
Contaminant (1)
of Concern —÷
ro
Sample ID Sample cc 0c
p c a) -c
Collected
DateDepth m a, c 6,
(ft. BLS) oO OccO
Line (3') 1/8/2009 3 <6.93 <5.37
Dispenser (2.5 - 3') 1/8/2009 2.5 - 3 <7.11 8.13
All results in milligrams per Kilogram (mg/Kg).
ft. BLS=Feet Below Land Surface
<=Less than reporting limit
No DRO or GRO concentrations were revealed above the NCDENR Action Level of 10
milligrams per kilogram (mg/kg).
Conclusions
The source of the sheen in the water adjacent to Pump #3 was identified by Creekside
Yacht Club personnel as a leaking pipe beneath the dispenser/pump. Pump #3 was
taken out of service, a portion of the supply line piping was removed and approximately
25 feet of piping was capped and abandoned in place.
A soil sample was collected beneath the former dispenser/pump location and from
beneath the end of the abandoned supply line piping. The two soil samples were
analyzed for TPH DRO and GRO by SGS Environmental Services, Inc. No DRO or
GRO concentrations were revealed in the soil samples above the NCDENR Action
Level of 10 mg/kg.
CATLIN recommends forwarding a copy of this letter and attachments to the US Coast
Guard, the NCDENR DCM and NCDENR DWM UST Section. If you have any
questions or require any additional information, please do not hesitate to contact us at
(910) 452-5861. CATLIN appreciates the opportunity to assistance you with your
environmental needs.
Sincerely,
iu` c
ATTACHMENTS
FIGURES
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'4 FORMER DISPENSER,,
`� LOCATION
40 ' " ,
' DISPENSER (2.5-3')
41.
4111 [<7.11/8.13]
' ABANDONED FUEL I e j0 LINE (3')
SUPPLY LINE f , F,. [<6.93/<5 37]Aillik
ie. :,. ' ,,,,... ,,4„. ...
t
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END
and Auger Boring/Soil Sample 'fig *-,��4�o
_x;fi,
?et Below Land Surface
liesel Range Organics/ '
gasoline Range Organics
it samples collected by CATLIN personnel on January 8,2009 y
d analyzed by SGS Environmental Services per EPA Method 8015
PHOTOGRAPHS
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reekside NC
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6334 Oleander Drive
Wilmington, NC
January 8, 2009
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6334 Oleander Drive
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January 8, 2009
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Wilmington, NC
Januar 8, 2009
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6334 Oleander Drive
Wilmington, NC
January 8, 2009
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Wilmington, NC
January 8, 2009
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6334 Oleander Drive
Wilmington, NC
January 8, 2009
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LABORATORY ANALYTICAL REPORT AND
CHAIN OF CUSTODY DOCUMENTATION
SGS Environmental Services, Inc.
Ben Ashba
Richard Catlin& Associates
P.O. Box 10279
Wilmington, NC 28404-0279
Report Number: G128-2297
Client Project: Creekside Yacht Club
Dear Ben Ashba,
Enclosed are the results of the analytical services performed under the referenced
project. The samples are certified to meet the requirements of the National
Environmental Laboratory Accreditation Conference Standards. Copies of this report
and supporting data will be retained in our files for a period of five years in the event
they are required for future reference. Any samples submitted to our laboratory will
be retained for a maximum of thirty (30) days from the date of this report unless
other arrangements are requested.
If there are any questions about the report or the services performed during this project,
please call SGS Environmental Services at(910) 350-1903. We will be happy to answer
any questions or concerns which you may have.
Thank you for using SGS Environmental Services for your analytical services. We look
forward to working with you again on any additional analytical needs which you may have.
Sincerely,
SGS Environmental Services, Inc.
Project Manager to /9/-- --
Ashley Nifong
SGS Environmental Services, Inc.
Results for Total Petroleum Hydrocarbons
by GC/FID 8015
Client Sample ID: Line (3') Analyzed By: DVG
Client Project ID: Creekside Yacht Club Date Collected: 1/8/2009 10:00
Lab Sample ID: G128-2297-1B Date Received: 1/8/2009
Lab Project ID: G128-2297 Matrix: Soil
Report Basis: Dry Weight Solids 87.63
Analyte Result RL Units Dilution Date
Factor Analyzed
Gasoline Range Organics SQL 5.37 mg/Kg 1 01/08/09 15:35
Surrogate Spike Results
Added Result Recovery Flag Limits
BFB 100 100 99.5 70-130
Comments:
Batch Information
Analytical Batch: VP010809 Prep Method: 5035
Analytical Method: 8015 Initial WWol: 6.37 g
Instrument ID: GC4 Final Volume: 5 mL
Analyst: DVG
SGS Environmental Services, Inc.
Results for Total Petroleum Hydrocarbons
by GC/FID 8015
Client Sample ID: Line(3') Date Collected: 1/8/2009 10:00
Client Project ID: Creekside Yacht Club Date Received: 1/8/2009
Lab Sample ID: G128-2297-1D Matrix: Soil
Lab Project ID: G128-2297 Solids 87.63
Report Basis: Dry Weight
Parameter Result RL Units Dilution Date
Factor Analyzed
Diesel Range Organics BQL 6.93 mg/Kg 1 01/08/09 22:16
Surrogate Spike Results Spike Control Spike Percent
Added Limits Result Recovery
OTP 40 40-140 34.5 86.2
Comments:
Batch Information
Analytical Batch: EP010809 Prep batch: 13393
Analytical Method: 8015 Prep Method: 3541
Instrument: GC6 Prep Date: 01/08/09
Analyst: EAW Initial Prep WWol: 32.94 G
Prep Final Vol: 10 mL
- - vc.� ■■■v■ •New Jersey •New York
CHAIN OF CUSTODY RECORD •North Carolina •Ohio
West Virginia
www.us.sgs.com
SGS Reference#: G(Zk—Z2Y7 r
(� page of /
1��(�1/4— PHONE NO:q(0 .(/S i �i l,(4
Preservatives r
f / SITE/PWSIDit: AJe.. VI # SAMPLE
Used
•t. I(L
�
u s Analysis
EMAIL:( amshkii,(2(<;t(rnuki� . (v 1 0 COMP Required
I N R= O �V
/1(y/�
T IRAs
QUOTE#: /VA A
V I MI= n e
P.O.#: Z`4O1 0 .�, NE Incremental Mugu '! (/7
MATRIX/ R Samples
�\ REMARKS!
DENTIFICATION DATE TIME MATRIX SCODE LOC ID IT
3) V Va/ "eq) Sc. / 3 6 v.-J
r(i.5-3') i`Vcq I/cO 5C. f C (l I/ V
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Date Time
77 Received By: DOD Project? YES NO Special Deliverable Requirements:
*4 //3.3 - Cooler ID _
Date Time ` ceived By: Requested TurnaroundTin a and-or Special Instructions:
Date Time Received By: t ' 2i y--- /
Samples Received Cold? YE NO Chain of Custody Seal: (Circle)
Date Time Received For Laboratory By: �\
— _, TB INTACT BROKEN B\,4 SENT 5