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Home My WebLink AboutNCD003200383_19900430_Koppers Co. Inc._FRBCERCLA SAP QAPP_Private Well Sampling - March 1990-OCRN. C. Oeparcment of Human Resources Division of Health Serv\ces State Laboratory of Public Health P. 0. Box 28047 306 N. Wilmington Street Raleigh, 27611 Site Number _o/.L..t:.:Jx.· _.,f>~_.Q"-'{)"'---3...a~"'--"f)L.J..f)<--,J.3-.e.J:',__,_.~.,__ ___ Field Sample Number __.{2..,,_,/,_,dJ""-'<'.)""-'3"""'-...,Z'--------- Name of Site fft1 ,,,,,ec,5 Co. , . 7;, c. Site Locaiion l1Zrvrr:cvt/.lt rr , .. ., /\/C Collected By KER roe I?« be.Rc,v, ID# .3 g Date Collected 3 -2 2. -90 Time Nd Type of Sample: Environmental ___ Groundwater ( 1) ___ Surface Water (2) __ Soil (3) Concentrate --.-Solid (5) __ Liquid (6) _·_ Sludge (7) _L Other (4) __ Other (8) 1r,j °F.J/ar1k. ~ INORGANIC CHEMISTRY Extractables Parameter Results mg/ I __ Arsenic __ Barium __ Cadmium _._Chromium __ Lead __ Mercury __ Selenium __ Silver ---------- P~ra1neter Results mg/ I _P&T:GC/MS __ Acid:B/N Exe. _TOX ..x.... ece <o-otwg-lR. J:,J..:!: -DJ-,,k • -- MICROBIOLOGY Parameter __ (MF) ·coliform Colonies/ IO0mls __ (MPN) Coliform Colonies/lO0mls Parameter Results mg/I __ Arsenic __ Barium __ Cadmium __ Chloride __ Chromium __ Copper ___ Fluoride . __ Iron __ Lead __ Manganese __ Mercury· __ Nitrate __ Selenium ORGANIC CHEMISTRY Parameter __ EDB __ PCB'.s __ Petroleum __ Endrin __ Lindane Results mg/ I . Parameter __ Gross Alpha __ Gross Beta Comments RECEIVED APR l O 1990 SUP£RFIJND SftTION Total Parameter Results mg/ I __ Silver __ Sulfates __ Zinc _Ph __ Conductivity _TDS _TOC -- -- -- -- -- -- Parameter Results mg/ I __ Methoxychlor __ Toxaphene _2,4-D __ 2,4,5-TP (silvex) -- RADIOCHEMISTRY Results PCi/1 Date Received 3 ~..13 -9 0 /3~4~Q_· ________ Date Reported if--f-: 90 l'ISIS', I /11S1>, I Date Extracted .;J-:U,r'/l>~ . Date Analyzed ~f--.:1~-9~o=tJ~l)~------------- Rcported By ~1 ~/lf~ Lab N-~~b;--_ -----'-9_0;_4c.___:_7_t.1.c:_,iS=---------":~_·_·_ .. !)HS 3191 {R~vised 7/85) ~ /L · · - c-•oliJ ,nJ H,mdou, Waste (Rev;ew 7/87) +--f-9'CJ T 7 '1/ S __.; tJ O Y, J lf-· CJ . ..s Purpose: Preparation • • .. Enforcement and compliance with the N. C. Solid and Hazardou~ Waste Managemerit Rules. A sample analyses request form (OHS 3191) must be completed for each rype of evaluation requested (e.g., . i[}organic, organic, microbiology, radiochemistry). For samplif1g Coriditiqns ,.'?lhit_h ·requir~ moi-e1 than one ( 1) cbntainer.(i.e., ground or.stirface water from landfills) 3. sample label must be affixed Co one Of the cOntainers. The . ~ . . ... .. ~ collectbr must then write the site and sample number on the dtiplicate. , • : ... · . .-}'. ' \ • ,t: . : --~• t r : • • .-· 1 ..., Do not submit an analysis reC}Uest sheet with no paramerers indicated~-f;•/ .• -. ) t, \ .. , .... .J,-.· .. -.. Equivalent measurements: gpm = µg/ml = mg/1 =µgig= mg/kg .'-: I·' ,:.,;ppb•F _µgl_l = µgllO00g = µg/kg DEFINITIONS/INSTRUCTIONS Site Number - A twelve~digit site/location identifier, assigned only by the district field representative. IMHT:-P?. UViU:llHqll,;. · Fielcl'Sample Number -A six-digit sample identifier which is pre-printed on the sample label. . ~. •,·.·_ •.. :\l-':•:: ... , .... ;\.· 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. Environrn~ntal - 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 hmited·to, sludges, resins, treatment effluents or drummed wastes. Comn1ents -Lists details regarding sample or sample point, including but limited to, phase separation, and/ or odors. Inorganic Chemistry -Check ( ✓ ) the desired parameters to be analyzed. Extracrables 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: 1. Original to State Laboratory of Public Health Environmental Sciences Branch Disposition: P. 0. Box 28047 Raleigh, NC 27611 2. Lab sends copy tO Solid and Hazardous Waste Management Branch. 3. Scilid and Hazardous Waste Management Branch sends copy to field person. '·. _< '\ J• .~.t-,: \I\ • .':". • '_ 1.\_ This form may be destroyed in accordance with the Environmental Health, Solid and Hazardous Waste Section of the Record, Oi,po,ition 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. 01:parcment of Human Resources Division of Health Services • • • SAMPLE ANALYSES REQUEs'r State Laboratory of Public Health P. 0. Box 28047 306 N. Wilmington Street Raleigh, 27611 · ~d-Q 0,3 J'_ 1 Field Sample Number -~()~/~,Q~t}~3=-,'j,__ _______ _ Site Number Name of Site Collected By Jn O,Jec,5. Co -~--;..D,JCL-.,,.c_____ Site l-ocation -~ -~r:'-'-r:~vtLLt.~~,.__,,,._.;V~_C~~-n-~- ~u..L~ ~D# ,3 g Date Collected ~~-= Z. -9 0 / Tune ~- Type of Sample: Environrnental ___ Groundwater ( 1) ___ Surface Water (2) __ Soil (3) _J_ Other ( 4) Concentrate __ Solid (5) __ Liquid (6) __ Sludge (7) __ Other (8) 5eltf 73 l,u, Ir:. f,t'-e(d l,/a,,/t:...~ INORGANIC CHEMISTRY Extractables Param.etcr Results 1ng/ 1 Parameter Results mg/1 __ Arsenic __ Arsenic __ Barium __ Barium __ Cadmium __ Cadmium _._ Chromium __ Chloride __ Lead __ Chromium __ Mercury _·_copp~r __ Selenium ___ Fluoride . __ Silver __ Iron --__ Lead --__ Manganese --__ Mercury· --__ Nitrate _._ Selenium ORGANIC CHEMISTRY Parameter Results mg/ 1 Parameter Results mg/ 1 _P&T:GC/MS __ EDB -. _ Aeid:B/N Ext. __ PCB'.s __ TOX __ Petroleum .x.._ be, t;_ < 0, o I '7J /.L __ Endrin _ L -.{)t.fkf 1 ·_·_ Lindanc . ;, ~,..,-,A _I..,.. • ,I 1}: __ ( J'4 y~ ? I 'J MICROB OLOGY Parameter Parameter __ (MF) Coliform Colonies/lOOmls __ (MPN) Coliform Colon_ies/lOOmls Reported By !~HS 3191 (Revised 7/85) •·' - l '-'----.l-.. -\Vl_n_ ff:>,..,i,.,u 7/P,7) __ Gross Alpha __ Gross Beta Lab Number Con1rncnts RECEIVED APR 1 o 1990 SUPERFUND SECTION Total Parameter Results mg/1 __ Silver __ Sulfores __ Zinc __ Ph __ Conductivity _TDS _TOC -- -- -- --! --I -- Param.eter Results mg/1 __ Methoxyehlor __ Toxaphcr\c _2,4-D __ 2,4,5-TP (si\vex) -- RADIOCHEMISTRY Re.su lts PCi/ 1 N. C. Df:partment of Human Resources Division of Health Serv\ces • • • SAMPLE ANALYSES REQUEs'f State Laboratory of Public Health P. 0. Box 2804 7 306 N. Wilmington Street Raleigh, 27611 Site Number Name of Site Collected By ~ (), 3 J' "l ----LtOffec.S Co_. , D, c. ~ /Ja,,t /)e_hi54 ID// ,3 g Type of Sample: Environtncntal __L_ Gro,rndwater ( l) __ Surface Water (2) __ Soil (3.) __ Other (4) Concentrate --.-Solid (5) ___ Liquid (6) __ Sludge (7) __ Orher (8) Field Sample Number _ _..{)"-"/~J~f)~L/~D~-------- Site )_,ocarion -,-/lJLlla'.'"-J-J.rL:c'-'"'v-t-'-".L_½=~,---~tY-:.-~C:. ______ _ Date Collected 3 -2 2 -'10 Time O.P30 Con11nents IOL RECEIVED APR l O 1990 INORGANIC CHEMISTRY SUPERFUND SECTION I Extractable, Para1neter Results n1g/ I __ Arsenic __ Barium __ Cadmium _._ Chromium __ Lead __ Mercury __ Selenium __ Silver -- -- -- P~ra1neter Results mg/1 _P&T:GC/MS __ Acid:B/N Ext. J2'7:, . <O,ol~f:i. _l>L. ~.Ol'ttJj_ »' LL 1./1 .,.,,~ ... .,i_,._ _. ('J'tJ-tt!) ?' J MICROBIOLOGY Parameter __ (MF) Coliform Colo.nies/lOOmls __ (MPN) Coliform Colonies/lOOmls Parameter Results mg/ 1 __ Arsenic __ Barium __ Cadmium __ Chloride __ Chrom.iurn __ Copper ___ Fluoride __ Iron . __ Lead __ Manganese __ Mercury· __ Nitrate __ Selenium ORGANIC CHEMISTRY Parameter _· _EDB __ PCB's __ Petroleum __ Endrin __ Lindane .Results mg/1 Para1netcr __ Gross Alpha _._ Gross Beta Total Para n1etcr Results mg/1 __ Silver __ Sulfates __ Zinc _Ph __ ·Conductivity _TDS _Toe -- -- -- -- ---- Paran1eter Rcsul ts mg/ 1 __ Methoxychlor __ Toxapryene _2,4-D __ 2,4,5-TP (silvex) --- RADI I -OCHEM STR\ Resu Its PCi/ 1 Dace Received _.,31r..-ci:2-:,.c-,3--~9~Q'"'-'/3=,l!J.==,~-· --'·--------Date Reported ==~--~-~~--------- . 7f°Sls'. I IT1t,04 /1151 s. I ftll,o'/ Dare Extracted _3_-~~4,~-~9o~tl~<JJ~~3~·~;;J~i'~-_,9~D~(!,=Q,,_A~A~----Dace Analyzed </-.l.-?0136), {-2.-9084) --"··-•-::--. ----------------Lab Number __ _.:=9c.Q=-c4c..7=-,qe.t 7,._· _______ ._.•i_G-_·:.r_,·. Reported By !)HS 3191 (Revised 7/85) ,., '" _ .1 ____ ,v, __ ,_,o .... ; .. ,.,?/FI?) I N. C. O°epartment of H~rnan Resources Division of Health Scrv\ces • • • SAMPLE ANALYSES REQUEs"f State. Laboratory of Public Health P. 0. Box 28047 306 N. Wilmington Street . Raleigh, 27611 Site Number '1,J D O 0 3 d-0 03 J' 3 Name of Site ---LtOffec.:>: Co. I 7), C. Collected By ~~~ ID/I 3 g Type of _Sample: Environm.cntal _L Groundwater ( l) __ Surface Water (2) __ Soil (3) __ Other (4) Concentrate __ Solid (5) ___ Liquid (6) __ Sludge (7) __ Orhcr (8) Field Sample Number _ _.rQ.L..-'1,J.',-Q..._.o"-'>!lc+I--------- Site ).,ocafion c-4J~oa-~~r~:~c~tct-L_'Lt==-7r' ~N~-c~------ Datc Collected 3 -2-2 -'f_Q ___ Time (),fSO Cornrnents HECEIVfD APR l O 1990 INORGANIC CHEMISTRY SUPERFUND SECTION Extractables Parameter Results rng/ I __ Arsenic __ Barium __ Cadmium _._ Chromium __ Lead __ Mercury __ Selenium __ Silver ---- -- -- -- ·, P~raxneter Results mg/1 _P&T:GC/MS __ Acid:B/N Ext. "el°I <o. '?Ji. * _f>L !: . 01 _.t;Q it Auel. -'· /,•, ... f,rt!)yo ?) MICROBIOLOGY Paraxnetcr __ (MF) Coliform Colonies/l00rnls __ (MPN) Coliform Colonies/lO0mls Paran1ctcr . Results mg/ 1 __ Ar6enic __ Barium __ Cadmium __ Chloride __ Chromium __ Copper --· Fluoride . __ Jron __ Lead __ Manganese __ Mercury· __ Nitrate __ Selenium ORGANIC CHEMISTRY Parameter __ EDB __ PCB:s __ Petroleum __ Endrin __ .Lindane Results mg/ 1 Para1neter __ Gross Alpha __ Gross Beta Reported By -------------------Lab Number )lHS 3191 {Revised 7/85) •·• ,,. , ,v,_ ... ,o •.. : .... ""7/A7\ Total Para1neter ·Results mg/ l __ Silver __ Sulfates __ Zinc _Ph __ Conductivity __ TDS _TOC -- -- -- -- ---- Parameter Results mg/1 --. Methoxychlor __ Toxaphene _2,4-0 __ 2,4,5-TP (silvex) -- RADIOCHEMISTRY I ' N. C. Department of Human Resources Division of Health Servjces • • State Laboratory of Public Health P. 0. Box 28047 306 N. Wilmington Street Raleigh, 276 ll SAMPLE ANALYSES REQUEST Site Number Name of Site Collected By '1:J l:> O t9 3 :J. Q 0.3 J'.-? Field Sam pre Number _....,f),....._1_:J_.D_,__~'-1~2--:: _______ _ Jo /)aer-.S Co. . 7J, C., Site Location dloa-1:.u-r.L.,u , ;VC rv , · -~ 7 k'E/e, toe Pu be.~ lD/1 .3 g Date Collected 3 -2. 2 -'to Time ___t2___2L__z Type of Sample: Environrnent·al Concentrate Comtncnts ~ Groundwater (I) ___ Surface Water (2) __ Soil (3) ____ Solid (5) __ Liquid (6) __ Sludge (7) __ Other (8) 4'/'p-J C3 /or(~ lhas.s RECEl\li:.b __ Other (4) A~R l O 1990 INORGANIC CHEMISTRY SUPERFUND SECTION Extractables Total Paran1cter Results n.1g/l Parameter Results mg/1 Paran1cter Results 1ng/ 1 __ Arsenk __ Arsenic __ Silver __ Barium __ Barium __ Sulfates __ Cadmium __ Cadmium __ Zinc _-_Chromium __ Chloride _Ph __ Lead __ Chromium __ Conductivity __ Mercury __ Copper _TDS __ Selenium ___ Fluoride _ _TOC __ Silver __ lron ----__ Lead ----__ Mangan~se ----__ Mercury· ----__ Nitrate ----__ · Selenium --ORGANIC CHEMISTRY P;ratneter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1 _P&T:GC/MS _EDB __ Methoxychlor __ Acid:B/N Ext. __ PCB's __ Toxaphcne _TOX __ Petroleum _2,4-D :L /'cf <0,01...w:rJL __ Endrin __ 2,4,5-TP (silvex) _ l>1..i,, .Dr"f/.f ' __ "Lindanc --~ -.... ·'"' . j __ .,,._· { f iJ'I ~~ MICROBIOLOGY RADIOCHEMISTRY Parameter ! Parameter . Results PCi-/1 __ (MF) Coliform Colonies/ IO0mls __ (MPN) Coliform Colonies/l00mls __ Gross Alpha __ Gross Beta Date Received .f -A. J -'l O 13& Date Reporred -;,,;?.7.,--~---==-r--------/"J.S1S'. 1 -m(<()'-1 /!JO ms,s-. I m v•'f Dare Extracted 3·-l'-•9o&Q ·J-;t"!"-90 fl/l Date Analyzed t/-~-90/319. '/-:l-906'9 Reporred 13y Lab :.;~b~~ --904749 __ ,;o;;J,c !.lHS 319! (Revised 7/85) ,,, , _,,11 •••• ,0 ..... : ... ,,.7/A.7, DIVISION OF l:iEALr::: s:::RVIC:::s, . . SOLID .u JJA2ARDOUS \.lASTE l-'J._liAGE!{Q;.R.!.NCT! _ _ •-~-,. Ch2.in of Custodv Record ~_f(Cf]~~[!J E2z2rdous \.l2ste Hateri2ls APR l O 1990 SUPERFIJND SECTION Loc2:icn of S2.mpl:i_ng: Gener2:.or Transporte!:' __ Storage Facility __ Dispos2.l ?2.cility L2.ndfill C=p2.ny ' s N amec___,_4'1:.;_1<0l''4~~()=e..1.r~,.5.;_-i.C='ol,-7-,-~:_Lfi=~=~"-'-.::Cc~ ___ Telephon e ( ___ ,) ________ _ bdciress 1/wy ,s::'f'. moco'.tinLh Collector's Na.me,,<££ A,y--&/:IJL 16. ' tJ sign2.ture ,Tele_phone( 71/9 ) '?--'3 3-z J!O I Date S2.mpled_--=.3==· =----... (:2"'-L/)"----_,9c.c(Jw._ _________ Time Sa.mpled cJcf'dO -· cJV 7 Type 0£ Process Generating ~aste'---------------------------- l"itld Sa.mple No. l)/d03t &l«O 1</ t{J/,;},11,,-() LJQIJ1/I IJ(,;;ov.1. ___ _ Cn~iD o: Possession: 1- 2.' 3. sig:1ature titie inclusive dates ;fmd-- s1.g-:-,2. Lure ti~le dc.te Ins::::-'Jctions: Complete c..11 2pplic2."ole infon::ction incluCir.g sign2.rures, c.nd submiL \.-~ir.h ·.anc.lysis reouest fems. . ' . \ lS,~§LQti.~ • . . CHAIN OF CUSTODY RECORD ,,,r CODE 1 "PROJE,+:-NAME . C cv---"' ( ,-• , "-C Dem~ '<-l.\e.l I \7'1:).50-0( NUMBER· J.... --'' "." "' .. -_, SAMPLERS OF ~ i:: ti.nature) ., (; REMARKS OR ...... _".-1\ -C\ n CONTAINERS .::, I r-17> /) .. ~ J OBSERVATIONS (I/ DATE C G w ~ 8 :i: STA. NO. TIME 0 " e STATION LOCATION 0. " A ' ' 8 ' [r,n (1,1,,.,/'.:_ x-n_-,cJ --X l I • -' X 2 I I h-elJ ()\,ok'.' I ()S''.Z.., j(.)-L 'x Gmc;e ;:son.,,s: Lj . . -=n• ;.;1 i 08':Jo a ;;i_ -I .. , 3.)_ -.J C.,ll.,1J' '-j &-d,_ -. ---Oli-.sO \/ /. ,,., (\rlr. .~n LJr.---:T ' J )( f'~lo~ ,·c, fY\os.<. '-{ )__ )_ I l"'I\ J u ;;J;;;JU "'' ;,~ 0"): 17 - ~ SU ERFI ND: ECTION ( Is ' . "-----"" ' ' rlinquished'by: (Si~--•·•r,:,l Date Time Received by: (Signature) _) R~liqu~d by-~(Signature~ Date nme . A~;;fj(Signature) V\J1 fl../\ () i D . 03-V--"lo D"dO (n L v-, rd V) I~ /c?1..--. / z,__ -,,-, ,. • ,·--,,_,, D ·7:yc, --· . /..-1~• /, .)-,.-:/. ~£: (Sig_nature) '~.~''-1/}fz/ mver1l!ii?9),tu~ l---Reliquished by: (Signature) Date Time Received by: (Signature) V ,, . !,"],.-;, 1 ~Reliquished by: (Signature) Date Time Aeceive9 for Laboratory by((Sif;;nature) Date I Time Ice Chest Temp Ice Chest Chain of Custody - QC 'if Tag# • DISTRIBUTION: Original accompanies shipment; Copy to Coordinator Field Files. ' ' ' - PAGE __ OF_ '· --__ .--~-· -.-.• - SAMPLE II 9o'/5<f (p 9o</st/7 :{-<!HlD~O < /,O <1. O /J/10-1~'- tJ// 0-,10 '-</, 0 <'I. o ;l-/J/TP-0 . 1'11€1-Jo '-< /, 0 < /, 0 ;/, t/ 'Illl1€Tlf-Yl- /J//£M)t.-< /, 0 <I. o <i?, </ .J)IC/ILO,f!o /'#t:.-YO'-< /, 0 < /, 0 ~o31>1€Tll'/I ~Jl€/JC)I... <I, o </,U ,?, 'I, t, T4Clf(.of!o <./, 0 < /, 0 •. -'DL .:,1 </ :1J1µ1 ne6 -..(, 5, 0 L..5. 0 J>tl€,-lot... J/-µne.o < /, c) l'lleJ..J ()(._, <I, o t/-f, lJi N ITP.. 0 -.c..5, 0 ' <5. () .:, · hleT/1/' (,, /'04n ClfLoR o <'l,o < /, 0 -f'fleNoL N.C. Division of Health Services . DHS 3068 (6/83 Laboratory) DEPARTMENT OF HUMAN RESOURCES -DIVISION OF HEALTH SERVICES LABORATORY SECTION OCCUPATIONAL HEALTH G C REPORT SHEET DATE OF ANALYSIS: ¥-~ -90 @ 9o i./S </J' 9oc/5Y9 <1. o <I. o < /, 0 < /, 0 < /, 0 < /, 0 HEf tEl\iFf1 <'l,o < /, 0 API 101990 <./, 0 <I, o SUPERI UNDSE < /, D <./, 0 <'I, u </.(.) < 5.o <S-.o <I, o <l,o <.S: 0 <S: 0 . < /, 0 </. () JL MEMO DATE: 2,-2-,~ -o/u TO:. ______ _ SUBJECT: -~'11 0/'.S J M"'-~ 11e~ :L,/ J wx!-v- ?fr /{! /J -/-cL-?t c{J ~~C.O ~~ hJ· ~ p Wui 0-u f t9 Vo ~ /~~ CT"J? :r _ C?'~-vu Am . · k~ 1: North Carolina Department of Environment, · ' Health, and Natural Resources ~ Loc2::icn of Sampling: DIVISION OF H.EJ..Lr:i S:C:RVIC:C:S_ SOLivl) HA2ARDOUS wASTE !-',J..NAGE!1:cN-R..!JKB Che.in of CustoO",: Re·cord E2z2rdous w2ste Materials Gener2tor Transporte~ __ Ireat:ment Facili __ Storage Facility __ Disposal ?acility __ Landfill ___._L..Other: (0-/f'-,6 Jg, d--t ,1 ;{)(),1 /J~ / , ttf fie-, Coo:pany.' s Name ,f:opµr,5 Co I ::z;,i,::_ r ~ Address &~ ,S:'f: /J?aco:an..LL.e Collector's Name YE£.,,{,,,.-& r-'AL 14 (I signature Telephone(. ___ ) _______ _ .Tele_phone(0'9) 7--:33-Z.PO( Date S ampled __ __.3=..----"o22'-LdJL-.-....,9'--()._.'--_________ T ime S 2.mp l.ed (),P clO -O 9/ 7 Ty;:,e of Process Generating waste. _________________________ _ . Field I:i.fonnation ·FiE.ld Sample No. l)JdtJ3J' t2lrx03'1 NdtJl/tl /JQIJ</l IJ/,Jo'/i ___ _ -I Cn~in o: Possession: 1. 2. t.it.le inclusive dates Res~~:s reported sig-r,c. t.ure date I:1s:::-uct:ions: Complete c..11 2.pplic2ble infon:;ation incluGir.~ signct.ures, and submiL \..~it.h ·.an2.lysis request. forns. ~ DIVISION OF EEJ..LTS SERVICES SOLID AND HAZARDOUS \./ASTE YJ.J,AGD-lENT BRANCH .eceipt for S2mules • The samples described below \..Jere collected in connection ,•ith the administration) enforcement., and ciocumentation of the: ( ) North Carolina Hazardous Waste Management Rules, 10 NCAC l0F ( ) North Carolina Solid Waste Management Rules, 10 NCAC l0G .( ) Comprebe!lsive Envirorunen tal Re.spcnse, Com.pensat.ior.. anci Liability P. ,.. .,. ·~-( ·1::--Ci ' ' ~ j.{ W~j ( ) Toxic Subs t:an.ces Control Act (TSCA). 15 U.S.C•. s2&01, .!:..!:.~-· specifically Section 11 of TSCA, 15 u.s.c. § 2610. ; ' Inspect:or:'s Name Inspector's Address ' 'Name of Firm ... Fire Address - ' Firm Owner, 0pe,·a ~or, or Agent Title - SAMPLE COLLECTED SAMPLE TYPE ·DUPLICATE SA..'t1PLES SA~LE LOCATION NUMBER DATE T~E WATER SOIL OTHER I OFFERED!ACCEPIED REJECTED I ON-SITE. OFF-SITE ---·-------7----. ·-· ~--.. I I I I I I I I I I I I Receipt for the sa.:aple(s) described. Receipt/rejection of duplicate or split above is hereby c.ck.nowledged: s2.1:1ples is hereby ackno,·ledged·: Sign2-cure of Inspector Sigr-,c.:u:-e of Finn 0-.mer, Opera tor, o::: Agen Title Tit.le COH!-!El\TS ~X.~T.Q~~ CHAIN OF CUSTODY RECORD r.t:!t CODE . PROJ'E't NAME ("Ii'--;? (;n'-17 "i a-5D-O( ~ (_, Or,,.,," '<... /.\el! NUMBER "" s SAMPLERS OF ')S ,::; (G-nature) CONTAINERS ~ REMARKS OR ·. ".J1 . G.n --fJ~ ~ ~ OBSERVATIONS 'L/ DATE C G w ~ 8 ~ STA. NO. TIME 0 ' E STATION LOCATION Q " ' l ,. B l I tr; n !'.11,.-( )/-t,.-k> --x l I I (-;,e\J 12,\,, IC I QS''.Z.,, X 2 I I 10-L. Oli':Ja X' Gl'Clc; e 00/l.Q> 4 ~ ;;i_ 3). -I o't,,so V /,\-,_J-C, 11.aJ' 'i a., d. LJrn-.T I I/ )( r.,, lo~;,;; /Y\as.<-lf )_ )._ ""-l,b 0"):17 -(ts '-----" - (elinquished by: (Si Date Time Received by: (Signat~re) ) Reliqu/4 by: (Si,tu,4 Date Time H:J-!;Ji,}Signature) -,,-·r-_fl r /) [ V., 03--0-"lo C:PdO (r\ l.v,rd i--".:)_ -L l,?jz_ .t:-_,,,.., s-1.-1-.-1 n 9. :'to "~2 ,;: (Signature) ,J;t Time r nre.d,f::!?t!.1~) J-/-Reliqulshed by: (Signature) Date Time Received by: (Signature) 'f<> 092I , Re'liquished by: (Signature) Date Time Received for Laboratory br.'(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_