NCD003200383_19900202_Koppers Co. Inc._FRBCERCLA SAP QAPP_Private Well Sampling November 1989-OCR

• •
State of North Carolina
Department of Environment, Health, and Natural Resources
Division of Solid Waste Management
P.O. Box 27687 · Raleigh, North Carolina 27611-7687
James G. Martin, Governor
William W. Cobey, Jr., Secretary
Ms. Shannon Craig
Program Manager
February 2, 1990
Beazer Materials and Services, Inc.
436 Seventh Avenue
Pittsburg, PA 15219
William L. Meyer
Director
RE: Koppers Co., Inc. Site, Mo=isville, N.C., November 1989 Sampling
D.lplicate Samples Analyzed by State Laboratory of Public Health
Dear Shannon:
Please find enclosed a copy of the laboratory results for samples
collected by KER on November 30, 1989 and submitted to the State
Laboratory of Public Health for analysis. No PCP was detected in any
_of these samples.
If you have any questions or require additionai inforrration,
please contact me at [phone].
PD/ds/koppers/ 4
Enclosures
Sincerely,
/2r
· Pat DeRosa, Erwironrnental C1J.emist
.Superfund section
Solid Waste Management Division
'·
' ' .,
State. Labora.ory' of Public Heal ch
N. C. Dcp:irtment of Hu1nat1 Rt.·:;ourct;S
1 Oi\'ision of Health ScrVice~ ' SAMPLE ANALYSES REQUEST
· Site Number
: Nan\c of Site
: Coilew,d By
~ Type of S:1rnp\c;:
.,
Environmental
_4-__ Groundwater ( I )
___ Surface Water (2)
__ Soil (3.)
. d Other (4)
r. · • , b ,. :n cco Ion I,(_
Concentrate
__ Solid (5)
___ Liquid .(6)
___ Sludge (7)
___ Other (8)
lNORGANlC CHEMISTRY
.
Extractable6
Parameter .Resi~~ts mg/1 Paran1cter Results mg/1
·--t\rscnic __ -Arsenic
___ Barium __ Barium
__ Cadmium __ Cadmium
__ Chromium __ Chloride
____ Lead __ Chromium
__ Mercury __ Copper
__ Selt:nit;m __ fluoride
__ Sdvcr __ Iron
' __ Lead ----__ Manganese
--__ Mercury -
--__ Nirrai:e
--__ SeleniuITl
.
ORGANIC CHEMISTRY
ParametCr Results~/1 Paiameter Results mg/ 1
_P&T:GC/MS _EOB
..:,.L Ac,d:B/N Ext. __ PCB's
_TQX __ Perrdeum
--w cM/1, .. < o,D I[)
__ Endrin
#-__ Lindane
Lr-, 0/,.1~/J ·
'"1.HCROBlOLOGY
i Paran1ctcr Pararucter
. I • __ (Hf) Coliform. Colonics/I00mls __ Gross Alpha
. __ (MPN) Coliform Colonies/!00mls __ Gross Bern
----
' ----
i
1. Datt: Recciv"ed /J. -/ -'o9 ,½8
Co1nn1cnt!-
.306 N. \Vi\rningrnn Strc.c.t
R,lci~h. 27611
-
Total
Para,nctcr RcsulLs mg/1
__ Silver
__ Sulfates
_·_Zinc
_Ph -·
__ Conductivity
_TDS
_TOC
----
--.. _
--
--.
--
Parameter Results mg/1
__ Mcthoxychlor
__ ~ oxaphene
_2,4-0
__ 2,4,5-TP (si\vex)
--
RADIOCHEMISTRY
Results PC ii l
• •
N. C. Dcpartmt:nt of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0. Box 280·\7
306 N. Wilmington Street
Raleigh, 2 7611
1 Site Number
I
__,9-'J"'-'D'-". ----=-e).=c(0_3"'--"',2,._. -"0-0"-""-~3'.'....u.!?~3='-----Field Sample Number -~/~/'--"'J?~f_._<J _______ _
' Name of Site ~/'Jditr,,5 &, .£;-,c,. SiteLocarion /J2or/}:1u-rLl<.. AIC ·.
/2".t:7L __ 1 _____ 10/i 3 !? Date Collected II -30 -o,9 I Time DfoS-
' Collected By ,,
., T ypc of Sample: ,
Environmental Concentrate Co1nrncnts
_ y/ Groundw;i.ter ( 1)
___ Surface Water (2)
___ Solid (5)
__ Liquid (6)
__ Sludge (7).
__ Other (8)
cf}fo ~J -Go:} ltl,.thC1S cf',<_:1cfluve
..
' "
__ Soil (3)
__ Ocher (4)
Extractables
Parall'.1:eter Results mg/ 1
__ Arsenic
__ Barium
__ Cadmium
__ Chromium
___ Lead
__ Mercury
__ SeleniUm
_. _Silver
------
----
Parameter J-~ Results /1
_P&T:GC/MS
...:,.L.. Acid:B/N Ext.
_TOX
--fft? cM I ;J' # z: 0. cil i'.)
L >=-, 0;-:1,1
, , MICROBIOLOGY
Parameter
__ (MF) Coliform Colonies/lO0mls
__ (MPN) Coliform Colonics/l00mls
----
' .
lNORGANIC CHEMISTRY --· -.
. Total
Parameter Results mg/ I Parameter Results n-tg/ 1
__ Arsenic _·_Silver
__ Barium __ Sulfates
__ Cadmium _·_Zinc
__ Chloride _Ph
__ Chro~ium __ Conductivity
__ Copper _TDS
__ Fluoride _TOC
__ Iron --
__ Lead --
__ Manganese --
__ Mercury· --
__ Nitrate. --
__ Selenium· --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1
_EDB __ Methoxychlor
__ PCB's __ Toxaphene
__ Petroleum _2,4-D
__ Endrin -. _ 2.4,5-TP (silvex)
__ Lindanc --
RADIOCHEMISTRY
Parameter Results PCi/ 1
__ · Gross Alpha
__ Gross Bern
--
--
Date RecdvCd /"-l-0
" ua --~-~ec~~~!l..-2~0.~u~-~---~----Dace Reported -----~-------------
D d i;).-::-s;<~Pt;_)
;i ate Extractc ~~~~~~-------------
: Reported By Lab Number
• • ,,
I N. C. D~partrnt;nC of Human ResOurces
~ Division of Hen Ith Services SAMPLE ANALYSES REQUEST
State L!h,,r~tory of Public !-!cal th
P. 0. Box 2804 7
306 N. \Vilmington Sm::et
Raleigh, 27611
{jJ. [) <910 3 ,2 u-0 3_,.,_J~3"'------Field Sample Number / / ?@
· Sit~ Number
Name of Sitt.:
Collected By
JJ241:111r ..s_<!J,_ --<-.C'c=L✓=..n~c...~---Site )...oca~ion ~ C,r/'1:1u-rLl<./ NC.
lcffl..../ I lD!i ___,3""'-'-'y"---Date Collected _i_L::_3 0 -o,9 Time _£1_9_ 3 5"_
Type or Sample:
Environmental
_J Groundwater ( 1 )
___ Surface Water (2)
__ Soil (3)
__ Other (4)
Conccn tratc
__ Solid (5)
__ Liquid (6).
__ Sludge (7)
· __ Other (8)
INORGANIC CHEMISTRY
Extractables
Parameter Resu Its mg/ 1
__ Arsenic
__ Barium
__ .Cadmium
___ Chromium
___ Lead
__ Mercury
__ Sdeniu"m
__ . Silver
--
------
--
Parameter Rcsults~/1
_P&T:GC/MS
_:,.,L_ Acid:!VN Ext.
__ TOX
--?}f<c,J-1~ ,;; 01 C/0 :A'-l-c.,Ol Id
MICROBIOLOGY
Pararnctcr
·, __ (MF) Coliform.Colonies/lQ0mls
__ (MPN) Coliform Colonies/\O0mls
I I
I l;'aran1eter . Results mg/1
I A . !--rscn1c
__ Barium
__ Cadmium
__ Chloride
__ Chromium
__ Coppei
__ Fluoride ---
__ lron
__ Lead
__ 1-.,{anganese
_._ Mercury ·.
__ Nitrate
__ Selenium
ORGANIC CHEMISTRY
Parameter
_EOB
__ PCB'.s.
__ Petroleum
__ Endrin
__ . Lindane
Results mg/ 1
P,1ramcter
--· GrossAlpha
__ Gross Bera
Comrncnts
Total
Parameter Results mg/ 1
__ Silver
__ Sulfates
_·_Z.inc
__ Ph
_._Conductivity
__ TOS
__ TOC
--. --
--
--
--
--
Parameter Results mg/1
_· _ Methoxychlor
__ Toxaphcne
_2,4-0
__ 2,4,S-TP (silm:)
----RADIO H·MI T C E S RY
Results PCi/ 1
·1 '--:-------'---------------------j__---~-~------------------
' a : Dae«: Recdved f,) -/ -gq ;68 Date Reported ----~---------.c_-
,, D E d l', __ ,_--',A.-';?C_/ 01,,,) · '! -, il'_. ?;,er fJ;r ·:
ate xtractc ~~--~-\~-~-~-----------Date ~nalyzcd ~~-~--~·cL·--~~'-' _-_·L._' __________ _
Lab Number
• •
t,,,!_ C. Dccparuni.:m of Hurn;rn Resources
Division of Hen.Ith Service~ . SAMPLE ANALYSES REQUEST
S.::i.tc. Lab-::-:Jtory of Pub!k !-lc;,.hh
P. 0. Box 280·\7
3C'C N. \\1ilmingrnn Street
Kaleigh, 27611
Site Number
Name of Sire
Collected Gy
· Type of Sample:
Environmental .Concentrate Co1nrncnts
I _v:__. Groundwater (I) ___ Solid (5)
__ Liquid (6)
__ ·_ Sludge (7)
___ Other (8)
_,/J)-L <6ca r , e · le(] f./c1 '
V
.
___ Surface Water (2)
__ Soil (3)
__ Other (4)
Extractables
Parameter Results mg/ 1
__ Arsenic
__ Barium
__ Cadmium
____ Chromium
___ Lead
, __ Mercury
___ Selenilim
__ Silver
--
--
--
--
--
P~ran1eter Rcsults~/1
· _P&T:GC/MS
_:o.L._ Acid:B/N Ext.
' _TOX
--
~l'M/11 -=A'-sJJ.O! 0
l ""' 0/~A/,f
, 1'l11CROBIOLOGY
INORGANIC CHEMISTRY
Total
Parameter Results mg/1 . Pararnetcr
__ Arsenic __ Silver
__ I3arium __ Sulfates
__ Cadmium __ Zinc
__ Chloride _Ph
__ Chromium __ Conducti\'iLy
__ Copper _TOS
__ fluoride __ TOC
_·_lron --
__ · Lead ,--
__ Manganese --
__ Mercury ·_ --
__ Nitrate_ --
__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter
_EOE __ Methoxychlot
__ PCB'.s . __ Toxaphcne
__ Petroleum __ 2,4-0
_· _Endrin __ 2,4,5-TP (silve>:J
__ .Lindane --
RADIOCHEMISTRY
Results mg/ 1
Results mg/ 1
Par.lmctcr Param.eter Rcsul,; PCi/ 1.
__ (MF) Coliform, Colonies/ l00mls --· Gross Alpha
___ (MPN) Coliform Colonies/l00mls __ Gross Beta
----
r---
Date Rec.civCd
· Reported By Lab Number
• •
· N. C. Department of Human Resoucces
-; Division of Health" Sc.rv\cc? SAMPLE ANALYSES REQUEST
State Lahorntory of Public Health
P. 0. Bo., 2804 7
306 N. Wilmington Street
Raleigh, 27611
·, Site Number
· Name of Site
, Collected By
:: Type of Sample:
Environmental
_-L_ Groundwa~cr ( 1)
___ Surface Water (2)
__ Soil (3)
t.'· __ Other (4)
IOI/
Con.cent.rate
__ Solid (5)
__ Liquid (6)
__ Sludge (7)
____ Other (8)
Comments
le~se·CA'-L'"'-l,_,_..,'---~----~
,_,;' .)_.
INORGANIC CHEMISTRY
Extractables
Parameter .Results mg/ 1
_. _r\rscnic
__ Barium
__ Cadmium
__ Chromium
___ Lead
,,
__ Mercury
_. __ Sdeni\im
__ Silver
---.
--
--
----
Paraineter Results~/!
__ · P& T:GC/MS
___:,.L'__ Acid:B/N Ext.
_TOX
" --.::A'-n,,,.., ,,,,, ;, , t..D,O/)
l'>L r-, 0/,i,/
, /I. tlCROB!OLOGY
Par~metcr
__ (MF) Coliform.Colonies/!00mls
__ (MPN) Coliform Colonies/l00mls
.
Parameter Results mg/ I
__ .Arsenic
__ Barium
__ Cadmium
__ Chloride
__ Chron:i-ium
__ Copper .
__ fluoride
__ Iron ,·
__ Lead
__ Manganese
__ Mercury ·_
__ Nitrate
__ Selenium
ORGANIC CHEMISTRY
Parameter
_EDB
__ PCB's
_._ Petroleum"
__ Endrin
__ Lindane
Results mg/ I
.·.
Parameter
__ Gross Alpha
__ Gross Beca
Total
Parameter Results mg/I
--Silver
__ · Sulfates
__ Z.inc
__ Ph
__ Conductivity
_TDS
_TOC
--
--
--
--
--
--
. Parameter Results mg_/1
__ M~thoxychlor
__ Toxaphcne
_2,4-D
__ ·2,4,5-TP (silvex)
--
RAO!OCHEMISTRY
Results PCi/ I
Date Recciv.ed _ _,/-'-J"----1._-_.K,_0
.,_I ,,_o<;-'-''(;i"-· ----'-------Date Reported -----~-------------
. . '-,
Dace Extracted I J-J;; .c,,_u Po.) J?atc ~nalyzcd _i_~_-~J::~•·_f_.·~~/_f_r._~-~--___________ _
Reported By Lab Number ___ · ~9~, '='.)~J~'"it~l=·;~s~--------
• •
N. C. Oi::parcmc.nc of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
Scact·. Laboratory of Public :-;,;;;,,\th
P O. Box 280·\7
306 N . .\X/ilrnington Street
Site Number
Name of Site
Collec,ed By
pf) =-,-R,kigo, 27611
9J b '9(0 3 ,2 o-0 3 Ll Field Sample Number l7g' $2? /I Cf tl 3
__ l/1:,::.¥13 1r s___0!, -
1
L
011
,1c.
3
· 0 Site locarion ,IJ?Ci r,Ct ,";1;-rL-47 Af(.
~?7<..____ ~--~o~--Date Collected // -.30-cf:J Time _,1._L2..._()_· ~
Type o( Sample:
Co nccn tra tc Comn1cnts
Environmental
~L, Groundwater ( I )
___ Surface Water (2)
__ Solid (5)
___ Liquid (6)
__ Sludge (7)
___ Ocher (8)
G!1eJ¼-112<. C!r1;-q.,_"):1..04 __ _
__ Soil (3)
___ Other ( 4)
Extractablcs
Parameter Results mg/ 1
__ :\r~enic
__ Barium
__ Cadmium
__ Chromium
___ Lead
__ Mercury
__ Selenilim
__ Silver
--
----
----
Parameter Results~/!
_P&T:GC/MS
_..:,.L__ Acid:B/N Ext.
_TOX
--
.c#--n' r ,,,,,, I,, Zc.',C•i/J
f'iL "'", 0/'4,/,1
',,-MICROBIOLOGY
Parameter
__ (MF) Coliform. Colonies/ 1 OOmls
__ (MPN) Coliform Colonics/!OOmls ·
--
--
Dace ReceivCd
'
lNORGANlC CHEMISTRY
Parameter Results mg/ 1
__ Arsenic
__ Barium
__ Cadmium
__ Chloride
__ Chromium
__ Copper
__ Fluoride
__ Iron
__ Lead
__ Manganese
__ Mercury ·_
__ Nitrate
__ Selenium
ORGANIC CHEMISTRY
Parameter Results mg/ 1
_EOB
__ PCB's
__ Petroleum
__ Endrin
__ .·Lindane
Parameter
__ Gross Alpha
__ Gross Beta
--
--
· -\'' 0C( {I \ Date Extracted __ ,_,'---'-·· _.,_-_., __ r_, ~-• ___________ _
Reported By
Total
Parameter Results rng/1
__ Silver
__ Sulfates
_·_Zinc
__ Ph
__ Conductivity
_TDS
_TOC
--
--
--
--
--
--
Parameter Results mg/ 1
__ Methoxychlor
__ Toxaphene
_2,4-0 -
__ 2,4,5-TP (silvcx)
--
RADIOCHEMISTRY
Results PCi/ 1
'Loc2:icn of S2mpling:
A DIVISION OF J:lVJ.,T::o S'::RVICC:~
SOL1~7) HA2.ARD0US \.lASTE l-'J.-1',AG_~3R.'-J,CR
Gener2t.or 7re2.trne.nt. F2ci}
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.
~X,~T.Q~.~ CHAIN OF CUSTODY RECORD
Pu;-~CODE I PROJECT NAME ;: R c.. ,~-:1J~,o, NUMBER 5:
SAMPLERS -OF ;:::
(i!l/;'"j,/) /4 ~~ CONTAINERS J REMARKS OR
. \ ~ OBSERVATIONS . C G w 'Z\.) 8 ~
STA. NO. DATE TIME 0 R E STATION LOCATION Q
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Refiqtiished by: (Signature) Date Time Received for Laboratory by: (Signature) Date ! Time Ice Chest Temp Ice Chest Chain of Custody
QC # Tag#
"DISTRIBUTION: Original accompanies shipment; Copy to Coordinator Field Files.
• PAGE __ OF_
.
.. . --C -
N. C. Department of Human Resources
Division of Healt~ Serv~ce~ .. _,:...,,
• SUPERfUND BRl\NCH •
401 O3Ef~UN RQJ.\D ·
SAMPLE ANA_L YSES REQUEST
State Laboratory of Public Health
P. 0. Box 28047
. 306 N. Wilmington Street
Raleigh, 27611
Site Number ·___,9ccd'""-.,_b"---'c9=(0'---"'3'-'J"'--"'a0:..,·"-·-"'3.,_,,R~3=<-----· Field Sample Number __ .7/_,/~,/>~~f.->,j'~--------
Namc of Site ·~ 1r ..S & , .Lt1C,. Site Loca;ion. /l2{!r,o,'r111U,(__ Al(
Collected By £if'_ ID# 3 f? • Date Collected // -30-<f,9 1
Time .
. Type of Sample:
Environ1ncntal
-4.... Groundwater ( 1)
___ Surface Water (2)
__ Soil (3).
_L Other (4)
Re.Jd blank.
Concentrate
__ Solid (5)
___ Liquid (6)
-.-Sludge (7)
-.--Other (8)
Corn1nents
"urc.11ru1w ~tLIIUN
INORGANIC CHEMISTRY
Extractable, .. .. Total .
Parameter .Results mg/1 Parameter Results mg/1 . Paran1eter Results mg/1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium _·_Zinc
__ Chromium __ Chloride _Ph
___ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Sclt:niUm., . __ Fluoride _TOC
' ..
· __ Silver __ .lrOn --
--__ Lead --
. __ Manganese -----
--__ Mercury ·_, --
--__ Nitrate. --
--__ Seleniui-n --
ORGANIC CHEMISTRY
P~rameter Results~/! Parameter Results mg/ 1 Parameter-Results rng/1
.
_P&T:GC/MS _EDB __ Methoxychlor ·
~ Acid:B/N Ext. __ PCBls __ T oxaphene
_TOX __ Petroleum _. -2,4-D
-__ Endrin __ 2,4,5-TP (silvex)
..:¢-T( 1 r NV1/1,. <o,DID __ Lindane --
l'JL ,,., O/J.l,1 ·
,--MICROBIOLOGY RADIOCHEMISTRY
Paran1c·tcr. Parameter Results PCi/ 1
__ (lvff) Coliform. Colonie.s/ lO0mls __ Gross Alpha
__ (MPN) Coliform Colonics/!00mls __ Gross Beta
----
----
Date Rccciv"ed Date Reported __ /._~_-~/~8"_-_,,f,_,_f _____ __:. __ _
Date Analyzed __,icc)cc-lu':Jc.,·~,_r/'--P,'-'W"""-------------
Reported By , M
DHS3191(R,visd7:s5) n=r() J!f-6'(-9d3(il r
..:::"1;,1., ... , µ.,.,.,.,.!,,.."" w .. .,_t,. (H.,.vi.-w 7/87,
Lab Number 903464
• N. C. Department of Hur:n,an Resources
Division of Healt~ Serv~ce~ ........ . SAMPLE ANALYSES REQUEST
:· . ' . . , : ' ". . : -
State Laboratory, of Public Health
P. 0.'Box 28047
. 306 N. Wilmington Street
Raleigh, 27611
Site N~mber · __,C/c..,d"'-Jb""--'='0.,,,D:_3~.;2,._,,&0"-"'-. ..,;,3.LUR~3,.,_,_ ___ . Field Sample Number _'--J./.c_/'--f,£,__,9----'CJ=---------
Namc of Site ~..-041 ,r.s & , .£nc,. Site Location . ,(J'} ()OJ,/IMl./4 A[C,
f ~ l -
Collected By tf L ID# 3 f? • Date Collected // -30 -<f''J . Time [),J' 0 Z)
Type of Sample:
Environmental Concentrate Comments
~ Groundwater ( 1) __ Solid (5) dfa J-Gay {,{),1 i:k/C1,Cd&fc0aee
__ Surface Warer (2) ___ Liquid (6)
__ Soil (3) -.-Sludge (7)
__ Other (4) -,--Orher (8) UEC 2 0 1989
INORGANIC CHEMISTRY SUPERFUND SECTION
Extractables .. Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
. __ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium _·_Zinc.
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ SeleniUm __ Fluoride _TOC -
__ Silver __ Iron ., --
--__ Lead --
--__ Manganese --
--__ Mercury .. _ --
. __ Nitrate . ----
--__ Selenium --
ORGANIC CHEMISTRY
P3.rarneter Results';;\:/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
_P&T:GC/MS _EDB ' ,. __ Methoxychlor ·
_.::.L.. Acid:B/N Exr.
. __ PCB'.s ' ' ' __ T oxaphene
_TOX __ Petroleum _2,4-D
---__ Endrin __ 2,4,5-TP (silvex)
:#-n'rNVII,, zo.010 · __ 'Lindane
nL .,,, OJJ./,t --
. "MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter R.;sults PCi/ 1
__ (MF) Coliform Colonies/ IOOmls __ Gross Alpha
__ (MPN) Coliform Colonies/lOOmls __ Gross Beta
.
----
----.
Dare Received _ _.,/~;)~-,_/-~RL9~M~{!i,..__~-------Date Reporred ----~-------_;_ __ _
Reporred By
Date Extracted ~l~·).~--'l"-\'-'-~~P_is~) ____________ Date Analyzed _,_l)~-l~YL-_,.,89,.,_'-'P;;)=-----------
903465
__________________ Lab Number __________________ _
DHS 3191 (R,v;sed 7/85)
Solid and Hamrdous Waste (Review 7/87)
Purpose:-
Preparation
•
Enforcement and compliance ~ith che N. C. Solid and Ha~~dous Waste Management Rules.
A sample analyses request form (DHS 3191) must be completed _for each type of evaluation requested (e.g.,
inorganic, organic, microbiology, radiochemistry). For sampling conditions which require more than one (1)
container (i.e., ground or surface water from landfills) a sample label must be affixed-to one ofthe containers. The ·
collector must then write the site and sample number on the duplicate.
Do not submit an an3.lysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= µg/ml =mg/I= µgig= mg/kg
ppb = µg/1 = µg/lO00g = µglkg
DEFINITIONS/INSTRUCTIONS
Site Number - A twelve,digit site/location identifier, assigned only by the district field representative.
Field Sample Num:ber -A six-digit sample identifier which is pre-printed on the sample label.
Name of Site -Name of landfill, facility, etc.
Site Location -Address, street number, state road, etc.
Collected By -Name and ID of sample collector.
Date and Time Collected -Self-explanatory.
Environmental -A sample of a naturally occurring substance such as groundwater, surface water or soils which
may be contaminated, .
Concentrate -A sample of a waste, including but not limited·to, sludges, resins, treatment ~ffluents or drummed
wastes.
Comments....:.:. Lists details·regarding Sample or sample point, including but limited to, phas_~ separation, and/or
odors.
Inorganic Chemistry -Check ( ✓ ) the desired parameters to be analyzed. Extractables are·only performed on a
solid or semi~solid. For routine landfill samples, check all parameters in the second and third columns.
Organic Chemistry -Check ( ✓ ) the desired parameter to be analyzed. If not listed, enter the name in the space
provided.
Microbiology and Radiochemistry -The Raleigh office should be consulted prior to sampling for either
of these.· ·
Distribution: I. Original to State Laboratory of Public Health
Environmental Sciences Branch
Disposition:
P. 0. Box 28047
Raleigh, NC 27611
2. Lab sends copy r'o Solid and Hazardous Waste Management Branch.
3. Solid and Hazardous Waste Management Branch sends copy to field person.
This form may be destroyed in accordance with the Environmental Health, Solid and Hazardous Waste Section of
the Records Disposition Schedule as published by the North Carolina Division of Archives and History.
Additional forms may be ordered from:
Solid and Hazardous Waste Management Branch
Division of Health Services
P. 0. Box 2091
Raleigh, NC 27602-2091
• N. C. Department of Hurpan Resources
Division of Health Servjce~ ... , SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0. Box 28047
. 306 N. Wilmington Street
Raleigh, 2761 !
. .. . .. ,.
' Site Number __,_9_.,d"'--'-b.<-:c9~<0::....,,3"-'J.,..' _aO,,c· -"'. c...3~Rw3=<----Field Sample Number / / ?{)1)
Name of Site -./.~J_.U-k-,._,:L,~µ· · c.<~CL.r._,,;,s..,____,e_1J~, ---=· e=C=,11_,_C.,."""-----Site Loca,ion . ,L22ocri,'1widd../ A[(.
Collected By l(d__ lD# 3 S · Date Collected // -30 -J','l . Time f)'f,3.S-
Type of Sample:
Concentrate Comments Environmental
L Groundwater ( 1) __ Solid (5)
__ Liquid (6)
__ Sludge (7)
__ Other (8)
.3 fl -, T ..!.e7lete aa oc: Allel'1
'
__ Surface Water (2)
__ Soil (3)
__ Other (4)
Extractable,
Parameter .Results mg/1
__ Arsenic
__ Barium
__ Cadmium
__ Chromium .
___ Lead
__ Mercury
__ SeleniUm· ·
__ Silver
--
--
--
--
--
P~rameter Result~/1
_P&T:GC/MS
_..:,,L Acid:B/N Ext.
_TOX
-~DtOIO ~ n. I? PN1/J,
. i)L ""' OYd/,1
',,-kUCROBIOLOGY
.
Parameter.
__ (MF) Coliform. Colonies/ I 00mls
-. _ (MPN) Coliform Colonies/l00mls
--
--
INORGANIC CHEMISTRY
SUPERFUNO SECTIOM
Total.
Parameter Results mg/1 ' Parameter Results mg/1
__ Arsenic __ Silver
__ Barium __ Sulfates
__ Cadmium __ Zinc.
__ Chloride _· _Ph
__ Chromium __ Conductivity
__ Copper _TDS
__ fluoride _TOC
__ IrOn --
__ Lead --
__ }vfanganese --
__ Mercury ·. --
__ Nitrate_ --
__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ l Parameter Results mg/ l
_EDB . -__ · Methoxychlor
__ PCB's -. __ Toxaphene
__ Petroleum _2,4-D
__ Endrin _· -2,4.5-TP (silvex)
__ .Lindane --
RADIOCHEMISTRY
Parameter Re.suits PCi/ l
. .
__ Gross Alpha
__ Gross Beta
--
--
Date Recciv'ed _ _,_/-"';;l'--....,_/_-_,,8''-qL..>C,.X.ufi...,_ _________ Date Reported ----~---------
Date Extracted ~J~;).._-_1_).._-'?9~~ew~---------· Date Analyzed ~1~2=--'-1!.~Jt=q~P_'a)_-----------
Reported Ely Lab Number ____ S~O~J_'-lt-"~-'6~6=---------
OHS 3191 (Revised 7/85)
"' •· 1 -

-
J 1 ,_ ___ ..J_,,_ ,VI--•-fD _,,:a,,. 7 /A7\
• N. C. Department of Human Resources
Division of Health Sc~v!ce~ .·. SAMPLE ANALYSES REQUEST
State Laboratory of Public Health ·)
P. 0. Box 28047
. . . .· . ,, . . ' ·. •,· ' .. . 306 N. Wil~ington Street
Raleigh, 2761 l
Site Number · ~9~d~D~-c9~~~3~J~~QQ~·· •~3~R~3~---. Field Sample Number _ ___,,/,.__.,/c_,,9'-'-IJ'-+/--------
Name of Site
. Collected By
•1Ji2Ay71 /C..5 & , . ..z::;,c__ Site J.,oca;ion . /J2{)ifi ;JIMl./4{.. Af(
f , l
,f'L ID# 3 fl Date Collected // -.3Q -<f',9 Time_L..0..L/£
Type of Sample:
Environmental
~ Groundwater (1)
__ Surface Water (2)
__ Soil (3)
__ Other (4)
Concentrate
__ Soiid (5)
__ Liquid (6)
-.-Sludge (7)
-.--Other (8)
/fl-L
INORGANIC CHEMISTRY
Extractables Total
Parameter Results mg/ 1 Parameter Results mg/1,. Parameter Results mg/1
__ Arsenic __ Arsenic __ sil~er
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium -·-Zinc
___ Chromium __ Chloride _Ph
___ Lead _·_._·. Chromium __ Conductivity
__ Mercury __ Copper _TOS
__ SeleniUm ,·. __ Fluoride __ TOC . . _· _ .. _ .. IrOn ·• ·•· . ..
__ Silver ' --
--__ Lead --
--_· _:Manganese --
--_·_ Mercury ·_ --
--__ Nitrate --.
--__ Selenium --
. ORGANIC CHEMISTRY
Paramet~r Results"m!.11 Parameter Results mg/ 1 Parameter Results mg/ 1
_P&T:GC/MS _EDB
. , _·_. Methoxy'chlor ·
~:,,!_ Acid: B/N Ext. __ PCBls ... '.:' ·--Toxaphene
_TOX __ · Petroleum .·. __ 2,4-0
--~-=I,,
__ Endrin _··-2,4,5-TP (silvcx)
~-<Q.0/0 __ .Lindane
L "", 0/4A/,!
--
',.-MICROBIOLOGY RADIOCHEMI TR s y
Parameter Paratnetcr Re.suits PCU 1
.
__ (MF) Coliform. Colonies/ I OOmls --· Gross'Alpha
__ (MPN) Coliform Colonies/lOOmls __ Gross Beta
----
----
Date. RcceivCd Date Reported -----~------------
Date Extracted -,-,.l'~J.--l~::l._-~8~9_P,_W ___________ _
Reported By
1."-{'3-oa PtJ Date Analyzed _,. ___ o--\-=--=-==-----------
903467 Lab Number
OHS 3191 (Revised 7185)
C"t:.1 --.l U-•-r.-l,....,~ \Y.f.,c,,. IQ "'"i"'ut 7 /A7l
•.. • • N. C. Department of Hurp.an Resources
Division of Health Serv!ce~ ••.-.;··· . SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0. ·Box 2804 7
-306 N. Wilm_ington Street
Raleigh, 27611
Site Number ·_,C/'--'J"'--'bl..L......:c,!)c.,(0ce_,3"---"',2'----"'0-0'--"<-·~3_,_,_,R~3='---,---. Field Sample Number --+-/_,/_9.L.-'/~).;),,,,,· --------
Name of Site _J.-~-1---"-'-"A'?.~u:'?1-,_-. uJC-'r.__,;,5..,____,r,,_,.,.l)c_,__, .....c:· ,:::c::,/'1c.,-,,,C..~-~-Site Loca,ion . ,/l2oca ;IIMffi/ A[(.
Collected By /Id · ID# 3 J> Date Collected // -:5() -J>j · Time I//S
Type of Sample:
Environmental
_J__ Groundwater (1)
__ Surface Water (2)
__ Soil (3)
__ Other (4) ..
Concentrate
__ Solid (5)
__ Liquid (6)
_-_ Sludge (7)
_____ Other (8)
Comments
itf-1-1 Jesse. <¼au,.s
uur LfifUl'HJ -)C,L, ! :Ul'l
' ~ . '
INORGANIC CHEMISTRY ., ..
Extractables
Parameter -Results mg/ 1
__ Arsenic
__ Barium
' __ Cadmium
__ Chromium
__ Lead
__ Mercury
__ Selenillm . " '. __ Silver
--
--
--
--
--
.
Parameter Results-~/ 1
_P&T:GC/MS ~ Acid:B/N Ext.
.
_TOX
--~ n 1r,,,,_,,1,, l0.O10
h L "" , 0 "!,/,,/ ,1
, ,, .MICROBIOLOGY
Parame.ter.
__ (MF) Coliform. Colonies/ 1 OOmls
__ (MPN) Coliform Colonies/lOOmls
--
--
Date Received /J-l-K9 cX8
Dace Extracted . I ;;i.JJ,_ 5tA pi)
~eported By
OHS 3191 (Revised 7/85)
C"".!.-1 ___ J u ____ ,l_, __ ,v, .. ~A /Oa .. :aw 7/R7\.
., ., Total ..
Parameter Results mg/1 Parameter Results mg/I
__ Arsenic __ Silver
__ Barium __ Sulfates
__ Cadmium . . _-_-Zinc
__ Chloride _Ph
__ Chromium __ Conductivity
__ Copper _TOS
__ Fluoride ____ TOC
. •"'
__ rrOn .. ' _, .. --
__ Lead --
__ Manganese •· --
__ Mercury ·---
__ Nitrate --
__ Selenium --
ORGANIC CHEMISTRY · ·-
Parameter Results mg/1 Parameter Results mg/ l
_EDB ' :·:;,,__, _· _-M,,"thoxyi:hlor ·
__ PCBls ' __ Toxaphene
__ Petroleum _-_-2,4-0
__ Endrin __ -2,4,5-TP (silvex)
__ 'Lindane . --
RADIOCHEMISTR y
Parameter R,,"sults PCi/ l
--Gross Alpha
__ Gross Beta
--
--
Date Reported -----~------------
Date Analyzed ~l).""-J~S~·f;q--"---'--'f&._J __________ _
Lab Nu.mber __ _,,,9'-'Q"-'J=->4'-->6,<.>8.,,__ ______ _
.. • N. C. Department of Hury1an Resources
Division of Healt~ ;3erv\ce~_ .. _,.·;· SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0. Box 28047
-.306 N. Wilmington Street
R;leigh, 27611
Site Number __,C/....,J.,..__.b~-=-'9-=<0--=3..,,J~¢0"--"'--..L3.L.UR~3~---Field Sample Number p.D fftf <1,,f' _ I/ 9 !) 3
Name of Site J.-1/J2_.....A'2q..;,½{l;, . .LL.1c,.__,,,;..s.,__,,{1__fl.,~, --=· "'C"-'n'-'·=c.=· --~-Site )..ocaiion 1?2c,co ;11r1L4 NC
/' I )
' Collected By ,f L ID# 3 !? . Date Collected II -3a -<f''j Time
Type of Sample:
Environmental
_J_. Groundwater (I)
__ Surface Water (2)
__ Soil (3).
__ Other (4)
Extractable,
Concentrate Comments
__ Solid (5)
__ Liquid (6)
___ Sludge (7)
____ Ocher (8)
!Jd-H {!/1 e_fkr Ilk 0---t mm 04
SUFERFUND SECHOM -
INORGANIC CHEMISTRY
Total
Parameter Results mg/ I Parameter Results mg/ 1 . Parameter Results mg/1
' __ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc.
_-_Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Seleni,Um. , .. ., __ Fluoride _Toe
__ Silver __ rrOn ..
--
--__ Lead --
--_-_ Manganese --
--__ Mercury ---
--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY .
Parameter· Results~/! Parameter Results mg/ 1 Parameter Results mg/1
_P&T:GC/MS -
... -_ ..
_EDB _· _ Methoxychlor · .
:...:.L._ Acid:B/N Ext. __ PCB'.s . . ' -. -_· _Toxaphene
_TOX __ Petroleum _2,4-D -
---__ Endrin _-___ -2,4,5-TP (silvex)
.:¢.. it'Y _,._,,/,, Zo,olV __ "lindane
l'>L =-, 0/,,1,/,1
--
'/'MICROBIOLOGY RADIOCHEMISTRY
Par3rnc'ter Parameter Results PCi/ 1
__ {MF) Coliform. Colonies/ I00mls __ Gross "Alpha
__ {MPN) Coliform Colonies/lO0mls __ Gross Beta
----
----
Date Received -~' d-=·--~1-_i=q~b<=Pi~---~-------Date Reported ----~-----------
Reported By
D -l~-11-~q (kl 1·., 15 oo D,\
ate Extracted ~------------------Date A_ nalyzed -'-'--<-'----'-"'--c..:'>.,--,J...c.rc;;'-<J-~-----------
9QJ4t69
---~----------~----Lab Number __________________ _
DHS319J (R,vised7/85)
(:,,l;,J .,.,.,11-1.,~,,_rrl,....,,. W!l<:tl' {R,-virw 7/87)'
DIVISION OF HL'-.1:r,; S'::RVIC'::S __ .
• ' • '. . -:· • ' -. ' • •• -·,. ) : ., • ' , • ·. 'f' • -·'
SOLIDl)'TI' HA1..ARDO~S ~ASTE. l-'J..NAGE!Z)-;-R.'-.J<CR.
enc.in of cUst·oa-.... Re·cord ---
B2z2rdous waste Materials
Loc2ticn of Sampling: Generator TransPorL.e:c __ Tr ea tme.n t
__ Storage Facility __ Disposal ?acility __ Landfill
~Other: • h. M11x2M.iJ·duH-'L4,;ECE!\f!;:~)
C=pany's Name -,L~c.S,cA. Z:,,c Tel.ephone( ,).1·1r:-(•_.;){l1CjQC]
Address /JJ,'Y/lr,'(tf1/.Le, / /1.(f SUPFRFIIMn ~Fl~Ti!lM
Collector's Name ff/s k ~ /~ Tele_phone( 9?1 ) 7:3;?-;;J.,:f()/ J -~ •-•••...•.. . signa tur_e
D2te Sampled -//-.-?tJ-£O Time S2.mpl.ed /J/57) -/l,5""0 ---,', '--'---=~~~-1-1-------------'
. :FielC: I::iformation-·
'-
·Field Sample No. //Rf,? /IJJ?f //'j(rQ · /i90/ II 9c'.l z...
Cn~in o: Possessiori: ' .
1. .....,.,::_12_,:-=LL,~,_-... --~:p...,---,-"'----=--c-,·'---'-e.....,<,,,J.L,.._., 1':-1'-'i; f----'~"""'w=...,._(1 ..... A..,.A,,/IL.r...__· ___ _
' -· signature 7 . tit2.e
l
2. /:i-/-89
signature inclusive dates
signc..ture title inclusive dates
ti-;:.le d2te
Ins::-uc-.:ions: Complete 2.11 2pplicc.ble info~ction includir.g signc.t.ures, 2nd
subrniL \.."it:h ·.anclysis request foros.
DIVISION OF EEJ..LT.ci S:::RVICES
SOLID AND BAZARDOU S WASTE Y~.NAGE!-lENT irCH •
.ceipt
. ~,
for S21nples -' .
The samples described below were. collected in cow1ection ;..~ith the admin:i.st:rc ·i:ion >
enf orcerneo t, and ciocumentation of the:
( ) North Carolin2. Haz2rdous Waste Management Rules, 10 NCAC lOF
( ) North Caroliuc. Solid Waste Management Rules, 10 NCAC lOG
, ) Comprebcn~iv_e Enviior.lilen tal Response, \ Compen:;ation and Liability .\ct ( Cl::RC-Lii.) ,
( ) Toxic Subsr.ances Control Act (TSCA). 15 u.s.c. §2601, ~~-, specifically
Section 11 of TSCA, 15 u. s .c. § 2610.
;
Inspecr.or:'s Name Inspector's Address
.
Name of Finn .. Fino Address
'
Firm Ow-n er , Op&.:·a :or, or Agent Tit.le
. .
SAl1PLE COLLECTED SAMPLE TYPE DUPLICATE SA}IPLES S.Aill'LE LOCATION
NUliBi=:R DATE Tl:S WATER SOIL OTHER I OFFi=:Rr:DIACCEPTED REJECTED I ON-SITE\ OFF-SITi=:
I
..
I
I I I
I I
I I
I I
I I
Receipt fo.r the sa:npl e ( s) described_ Recei?t/rejection of duplicate or split
above is hereby c.ck.nowledged: s2.I:lples is hereby acknm:ledged·:
Signature of Inspector Sigr,c. .::u.':'e of Firm 0-wI1er, Ope:r2t.or, o:: Agen
Title Title
COtf!-fEKTS
~1:~r.2~.J? • , ,
CHAIN OF CUSTODY RECORD . .
ppf/c!DE I PROJECT NAME ;:
(-X:, -:J. J r::, 0 I NUMBER s::
SAMPLERS OF ;::
(5J!iiure) JJr; ~ REMARKS OR
' I h it ,Ac;,.---CONTAINERS
, v~ ~ OBSERVATIONS ... C G w 8 :i:-
~TA. NO. DATE TIME 0 R E STATION LOCATION '\ Q
" ' ' ----,. B '
Ff O.J A IA NJ. JI. ,~.< o'ti'O ,.,..-L-,,
:). 6 .;.r " oqss v C. nP V L, ll'JTl,t._,-,.1 S II
30-J ,, 0 'is.C -; <._Pl,:('nAJ,,,? 41/e/V I I
//J -L 1/ ,o'-15" . ?, ,I) t'1 C.,. I'.. ::r e. J'I.) I<, 'r,1--, II
i'f·f/ ;, )I I,-_,, st?.,., ... , C,!Jr1,11 (' fl·
;;);). -1-1 'I I/So . -· CHes 1<: f.!.. IV/ tCRi .,,W1v11 II
•
.
Rel~~vl:1,,;.,
Date Time Received by: (Jgnature) Reliquished by: r;}1_:ature) Date Time ~e'Jtvt::},r{.nj):tn,§'Jn--i /(• 3tr~ //5< t.J hr L. , /1,,,,,,, ,,./ .-1 t. / /9-7-C, -%' 1/-J{)·J' ,,:JS'
Ro/')'lu}'ihed by: (Signature) 1,,w}jP, Time Received by: (Signature) ' Reliquished by: (Signatifre) Date Time Received\tly: (Signature) .
TZf./lY/A OJ>~.)_ Mt,_, G cp,." -~· /J/i /RC!
Reliq'uished by: (Signature) Date Time Received for Laboratory by: (Signature) Date I Time Ice Chest Temp Ice Chest Chain of Custody .
OC # Tag#
*DISTRIBUTION: Original accompanies shipment; Copy to Coordinator Field Files.
PAGE __ OF_
_ DIVISION or HEJ.lrf s:::Rvrc:::s -· _
so'i:h,,'D, BAZ.A.RDOU s WAS TE \,j,N i,:c;, {~ cii''
Cncin of c·usi-od'" Re·cord
B2z2rdous ~2ste H.aterials
Loc2:ic::1 of Sampling: Gener2t:or Transporte~ __ Ire21:ment F2ci1:
__ Storage Facility __ Disposal ?acility __ LandbJ.l
-~ 0 ch er : _ _.~"'.-FIi-'=-_ ~t1----~cf~'A==Lil~• ~P~t1=i1~,"'~-f..,_,{_,,,.· ,~t-f~/-1-,~_ -------
Coo:pany, s Name -,d'.'~cs, 6 z;, c Telephone ( , ) _ ---------'--c--,-----
' Adoress __ ~/J}'-"-Lc{)r.,,:C...L/1.:..11c...,"1,__,t(1"-· ,,..L"--"''./4!.'=b----f/~Ac..:c/,'-'-(' __________________ _
Collector I S Na1ue ___ _,,fiu....:::~=--.L./s=..c-___.,z{:'-"-'-,~~~-><C=.L-C-~=t<-~---Teleyhone ( 'r( CZ ) Z:"3 ':?-:.M' () /
.Si~
D2te S2!11pled -//-/?IJ -£Q Time S=pled cQc(:57) :..,_ / /,5'Q -~,'-'--~"-"~~_,_/______________ '
Type o:: Process Gener2.ti:ng ~asce -------------~------~---
. ?ielC: luformation
// 9<'.J 2.., _J/9(),3
Cnc.i~ o: Possessiori:
2.
signature inclusive dates
3.
sig-;.1c..ture r.itj_e inclusive dates
sig-;-,2. Lure ri;:.le dc.te
ins:::-uc~ions: ·. Complete c..11 2pplicc.ble inforc2tion includir.~ sign2.cures, 2nd
submit. \.."'ith ·.2n2.lysis request forns.
-
KEYSTONE CHAIN OF CUSTODY RECORD ~/lite/~ EN\IIRONMiNT AL RtsOURCU, INC
I
PLf;:},CODE I PROJECT NAME fJ (.. r-:;4-:::i ;) r::: ,O I NUMBER
SAMPLERS . OF
r11/::J;J/4h-CONTAINERS
L,\ .. C G w •o--""'-
~TA. NO. DATE TIME 0 ' E STATION LOCATION ~ (.) Q
M A L -. ,. B L
F i (. kl I', U) Al/. . I!-<o-' o~O 1...-,..,.,. II
' J.6--7 ,, 0'6.sS v c;~P V t,r 111 rl.t..1-,.I S II
.30-J
,,
0 'i3!: -L-1.€./Fl'-11""" /.!,//er, ' I I
'/J -L I/ . !O'i5° ... -· t'.:t>J1r.,·t .s t,vi<,fl/S 11
I l/-H ,, )I 1, ,./ J.,, ....... ,, C.li,t;v1,.. II
) d -1-1 I I JI S-o -· CHes rr: I< f'/1 cCa..ilflM()YI ,,
-
' '
Relin~ig~ Date Time ij/cJ-be7;:ur✓ A ;·,H,~y '9;:z., Date Time n·,r~d by: (Signjfl~
,:;; '//, //-?,/}'< /JS<,' v-IP·J ~ 1:JJ' ". ~.,....,IL
~d J)_Signature) ,ti~ Time p<J;::lbvt:::::i-~/1/t'f Reliquished by: (Signature) Date Time '"Received~: (Signature} ~-
f9 Ip; OJ)s.).
Reliq'uished by: (Signature) Date Time Received for Laboratory by: (Signature) Date I Time Ice Chest Temp Ice Chest Chain of Custody • i -
•01STRIBUTION: Original accompanies shipment; Copy to Coordinator Field Files.
OC # Tag#
PAGE __ OF_
'
~~~T.9.~.1? CHAIN OF CUSTODY RECORD
PLfA/ CODE I PROJECT NAME ~ R._ C.. /?Dr? Jc; ,0 I NUMBER s;:
SAMPLERS OF .. ,:::
(~J/4A.i-CONTAINERS ~ REMARKS OR
v~ ~ OBSERVATIONS -. C G w 8 t !,TA. NO. DATE TIME 0 R ' STATION LOCATION "{ " ' ' . , . B '
Fi c. kl 611;/I/. o"'-50 // J.-II ,,_ ),,:;.~
J.6 -..r ,. o~ss V Gnt. v vtifl T/l-1/V 5 II
"',3o -J ,, 077£ -l ~e./t;L</1/ln/l A lier, . I I
Yo-L I/ 10'-15" . -0Rfl.c.,e. .:J t,vf<J"r,,'S "
t '-f-H ,. )I I~---~,,, ..... ; C. IJ11v 1 ,-II
J? -1-1 'I JIS'O -CHcs r.·t /It cCR.i NJfY,UY. 11
.
"I; ,r ' '.
Relinquished bynignature) . Date Time Received by: (Signature) t0/P~7~ Date Time
! 1J°f/~~d by (SAgnl!-{{I f) a'l '.#/lU<--0: v~ /f-3(}-v,; //SJ t.J /c)-i-J tJ-v, ,j ,1,. w-JP-J ,;, 1:J.f
~d~ure) /J)/J4j Time Received by: (Sig:.i--J Reliquished by: (Signattfre) Date Time 'Received·bY: ($ignatur8) ..
1/,f. 0/5;1. ~ C,. '-/j;v_, /.) I /g9
Reliq'uished by: (Signature) Date Time Received for Laboratory by: (Signature) Date ,j Time Ice Chest Temp Ice Chest Chain of Custody
QC # Tag#
*DISTRIBUTION: Original accompanies shipment; Copy to Coordinator Field Files.
' PAGE __ OF_
'