NCD980602163_19840525_Warren County PCB Landfill_SERB C_Treatment works influent and effluent analyses - Leachate pumping event-OCR

Ronald H. Levine, M.D ., M.P.H.
DIVISION OF ·HEAL TH SERVICES
P.O . Box 2091
Raleigh, N.C. 27602 -2091
MEIDRANDill-1
TO:
FRCM:
SUBJff:T:
O. W. Strickland
Tan Karnoski~
PCB Landfill
May 25, 1984
May 3, 1984 Leachate Treatment
Attached are copies of treatment works influent
ST A TE HEAL TH DIRECTOR
and effluent analyses fran the last leachate purrping
event. The effluent meets acceptable standards.
'ICK:ns
Attachrrents ( 2)
James B. Hunt, Jr/ Sarah T. Marrow MD. MPH STATE OF NORTH CAROLINA DEPARTMENT OF HUMAN RESOURCES ' ' GOVERNOR SECRET ARY
N. C. DEPARTMENT OF HUMAN RESOURCES r J
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Numbe r_'i__,;,_;:]=---_O_;;._o_,o:::;..:;.o_o;:.._.:..l _;0;:__;;0;.....;:0~)(,.__ _______ F ield Sample Number ()_ O I z 'i ,
Name of Site pc_ [? l f Site Location Tf?IAT1"'1f,,vr "-Y>,t~J tl\J8,<JE~1"
Collected By____,r;""'A= ... 2.:..:tv"'"'()"-"'S=~af ____ ID/1 __ --=-/ ..:;.S"' ____ Da te Collected .d J/ g l( Time eJ 'r.10
Type of Sample:
Environmental
Groundwater
Surface Water
Soil
Concentrate
Solid
/Other
Extractables
Parameter Results mg 1
Arsenic
Barium-
Cadmium
Chromium
Lead
Mercury
Selenium
Silver ·
Parameter · Results Iilg/1
Endrin -Lindane -Methoxychlor ---
• Liquid
Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Results mg/1
Arsenic
. Barium
Cadmium
Chromium
Lead
,Mercury
-Selenium
Silver
ORGANIC CHEMISTRY
Parameter RP.!=m1 tc: m,;,/
-Toxaphene
2,4-D -2,4,5-TP(Silvex) -
--
Comments
Parameter
Chloride
_ Conductivity
_ Copper
Fluoride
Iron
Manganese
Nitrate
_pH
Sulfates ·
TDS
Zinc
TOC
L JUl?llr C> rrt
Parameter
_k(PCB's
Petroleum -EDB -TOX -
-
Results m•/1
Roc-.. 1 t-,-. -~
D,la (dp f,' r
MICROBIOLOGY RADIOCHEMISTRY
Parameter
(MF) Coliform Colonies/lOOmls -·-(MPN) ·coliform Colonies/lOOmls ---
Date Received S" -I{-~'f
Date Extracted S-LJ.. -'t_ Y
Reported By
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
Parameter Results PCi/1
Gross Alpha -Gross Beta --
-
Date Reported 5-:J/-JL/
Date Analyzed 5'-JS-<; y 6£
Lab Number -102.154-
N. C. DEPARTMENT OF HUMAN RESOURCES ,
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number Cf 3 -00{:)0t::> I t>OO X Field Sample Number i!>Of 2S-O __;;;_.::;. ___ ----'----pr~ L,:,. Name of Site_. _'::'.Q_..__-=-''--_____________ Site Location l'tMT,._,E~:t wo iKl ~ F,-.<.cJJ:AJ r
Collected By KA1?ND~, ID/I Is-Date Collected shls'-1 Time (D.Jo
Type of Sample:
Environmental
Groundwater
Surface Water
Soil
/Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Results mg 1 Parameter Results mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
-Silve
Parameter
Endrin -Lindane -
Results mg/1
Methoxychlor ---
Arsenic
. Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
ORGANIC CHEMISTRY
Parameter RE>c::11ltc:: m,;,/
-Toxaphene
2,4-D -2,4,5-TP(Silvex) -
--
Comments
Parameter Results m•/1
Chloride
_ Conductivity
_ Copper
Fluoride
Iron
_. Manganese
Nitrate
_pH
-Sulfates·
TDS
Zinc
TOC 7 JU1?Blt>1I\::
Parameter
~PCB's
Petroleum -EDB -TOX --
'Roc,,,1 t-..--,.
<D-1 (¥>6 r
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls _Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta --
----
Date Received ____ £"--~V-_f::....,..~_,.-----Date Reported _ _,,-2~-----=:;;2___,_/_--=-?_,_f ________ _
Date Extracted 5 fj -8'9 Date Analyzed_-=5_-_,_/-=.5""'-,--..... £'---'-/ _ _,8.=--=-='/~=.;:;;_ __ _
Reported By ______________ Lab Number. ______ •1_0_· _;~..:..>....=..:!5"""-1..5"------
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number q .1 -oOovr•; i ()OC:J'X Field Sample Number ~O t 3 8'{
Name of Si te __ P_C_B_L_/-_· _____________ Site Location l.J+<J SI!,
Collected By_-----'J-~L.:-~"--v...::.....:::..o=s=rit ___ ID{f ________ Date Collected 6.{1, /gl.( Time
Type of Sample:
Environmental
Groundwater
Surface Water
_LS oil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Par ameter Results mg 1 Paramet er Results mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
Parameter Results mg/1
Endrin -Lindane -Methoxychlor -
--
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
ORGANIC CHEMISTRY
Parameter ReRulrc: mo/7
Toxaphene -2,4-D -2,4,5-TP(Silvex) -
-
-
Comments
Parameter
Chloride
Conductivity
Copper
Fluoride
Iron
Manganese
Nitrate
pH
Sulfates
TDS
Zinc
TOC
Parameter
~ PCB's
Petroleum -EDB -TOX -
-
MICROBIOLOGY RADIOCHEMISTRY
Results m1 /l
Rac .. l t-~ --/1
<", I -//-l11.
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls Gross Alpha --(MPN) Coliform Colonies/lOOmls Gross Beta --
--
--
Da t e Received <!;-?-Y"Y Date Reported {p-j_c./--Y 1/
Date Ex tr ac ted___{e_·-....... lc....3=· _-_t_Y,::___ _____ Da t e Analyzed===U=p=-=-1:=1==-=-/i==v===,tj=='.62.==-=======
Rep orted By~ -~---Lab Number _____ 4_~_ .. _3_1_~_)_1 ______ _
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= pg/ml= mg/1 = pg/g = mg/kg
ppb = pg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number -A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number - 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 ground-
water, surface water or soils which may be contaminated.
Concentrate -A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
' I
\ -. N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number 'fJ ~or:'[OD , {i)f)O X Field Sample Number (!)C, I 3' ~ 2
Name of Si te __ r'_C---"-/1_(,;;_:F'--_____________ S ite Loe a tion_-"/c.....,.C:........,,,0,:.::Sec..14:...:._ ______ _
Collected By_--'~'--L-A-'-R_1v..;;._;:;_t>-=S=JC.:::..,{ ___ IDII ________ Da te Callee t ed b /4 /5r'-( Time U>OO
Type of Sample:
Environmental
Groundwater
Surface Water
/Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Comments
Pa r ameter Results mg 1 Paramete r Results mg/1 Parameter Results m /1 ~--.....::..;:....::.;_ ______ _c...:....::...::...::...----=,.;z_:_:::i
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Seleni
Silver
-
Arsenic Chloride
Barium Conductivity
Cadmium Copper
Chromium Fluoride
Lead Iron
Mercury Manganese
Selenium Nitrate
Silver _ pH
ORGANIC CHEMISTRY
Sulfa tes
TDS
Zinc
TOC
Parameter Results rag/1 Parameter Res
-
-
-
-
Endrin
Lindane
Methoxychlor ____ _
Toxaphene
2,4-D
2,4,5-TP(Silvex) ---
Petroleum
EDB
TOX
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter
(MF) Colif orm Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta -
-
-
Results PCi/1
Da te Received J-)-F/ Date Reported &-/S"'" -tf'c/
Date Extracted {p --/½ f'<I Date Ana lyzed----={p:;...__-_,__/_J ___ y _ __,__1/ __ t?J.Q_, ---
Rep orted By Lab Number 4~ :31.~:C~ ----------------------------------
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm = pg/ml = mg/ 1 = pg/ g = mg/kg
ppb = µg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number -A twelve-digit site/location identifier, ~ssigned only
by the district field representative.
Field Sample Number -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 ground-
water, surface water or soils which may be contaminated.
Concentrate -A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
\ ,
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Numb er q 1-C'of.'t,;JC-/C'OtYJ<... Field Sample Number ()0 /J ~ J
Name of Site /JC{!, lf Site Location le.CDS /J
Collected By IC~ (l,vO S /(;/ ID/f ________ Da te Collec te_d_t..a.=,/1,~/...:,;c...sr--'l/--='--T-1-. m-e--l o_o_o_
Type of Sample:
Environmental
Groundwater
__ purface Wa ter
✓s oil
Other
Ex tractables
Con centra te
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Comments
Parame ter Results mg 1 Par ame t er Results mg/1 Pa r ame t er Re sults m /1 1--....=..;~=-------_.::..._.:....::...::..c::.......c:;;."'-'---~ Arsenic Chloride Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silv.er
Barium Conductivity
Cadmium Copper
Chromium Fluoride
Lead Iron
filercury _ Manganese
Selenium Nitrate
Silver pH
ORGANIC CHEMISTRY
Sulfa tes
TDS
Zinc
TOC
Par ameter Results rag/1 Par ame t er Re R111 t s m o /· Parameter
Endrin Toxaphene vPCB's --Lindane 2,4-D Petroleum ---2,4,5-TP(Silvex) Methoxychlor EDB ---TOX ---
---
MI CROBIOLOGY RADIOCHEMISTRY
Parameter Parameter
(MF) Colif orm Colonies /lOOmls Gross Alpha -(MPN) Colif orm Colonie s/lOOmls Gross Beta --
--
--
Roc,,1 t-c rnn /1
<. ~, l bD_fl1 Tl
Results PCi/1
Dat e Rece i ved ____ ....;:~:.........,.--....c.2:_-_=:;~~'Y'----____ Da t e Rep or t ed __ &J=----~/__,,S......___-,_J?,_-'{'-------
Da t e Ex tr a c ted __ /4.___.J_/__,</.__-..... J'---(,? _____ Da t e Analyzed_--,,-'{r___,o'----.._J_S_-_-~£--L-c/_-'--/3'_L)~--
Repor t ed By Lab Numb e r 4:: :31~3 • ----------------------------------
DHS 3191 (Revise d 2/84)
Solid and Hazardous Waste
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= µg/ml = mg/1 = pg/g = mg/kg
ppb = µg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number -A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number - 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 ground-
water, surface .water or soils which may be contaminated.
Concentrate -A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number ~3 -UV<:,c;o, ()(,If) X
Name of Site /6( fl Lf-
Field Sample Number (90 l'J ~'(
Site Location __ /c_C~LJ~S=~'-'--------
Collected By _ _.;_/(_,,,q.c..uc,:gc.:.;1a,1::....o:::....,,:S:...,:lt::~/'----ID// ________ Date Collected 1;/,f<tLf Time tZ.lo
Type of Sample:
Environmental
Groundwater
Surface Water
7soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Results mg 1 Parameter Results mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
Me-f"ctfr=-y ,&:-......,__.........,,......,.._
Selenium 1/ ~-~-----
Silver , _?) -.
Parameter Results mg/1
Endrin -Lindane -Methoxychlor -
--
Arsenic
Barium
Cadmium
Chromium
. Lead
Mercury
·selenium
Silver
ORGANIC CHEMISTRY
Parameter Res11lrs mo/
-Toxaphene
2,4-D -2,4,5-TP(Silvex) -
-
-
Comments
Parameter
Chloride
Conductivity
Copper
Fluoride
Iron
Manganese
Nitrate
pH
Sulfates
TDS
Zinc
TOC
Parameter
\/'PCB Is
Petroleum -EDB -TOX -
-
Results m /1
Roc-,,1 +-~ m~ /1
<1J , IP/> NJ r
MICROBIOLOGY RADIOCHEMISTRY
Parameter
(MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls -
-
-
Date Received ~-7 -P-~
Date Extracted 6--1.✓-tf tf-
Reported By
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
Parameter Results PCi/1
Gross Alpha
Gross Beta -
-
-
Date Reported &-15--J?/
Date Analyzed b -1£-? ✓ e&
Lab Number 4 ;.,.312-1
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm = pg/ml = mg/1 = pg/ g = mg/kg
ppb = pg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number - A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number - 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 ground-
water, surface water or soils which may be contaminated.
Concentrate - A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
I •
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTii SERVICES
STATE LABORATORY OF PUBLIC HEALTii
P.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number Cf' .J ··c)C>f'! ·01 (.,~_,() X Field Sample Number o o / J 78
Name of Site PcrJ l;: Site Location LJ TOS/9
Collected By_--:k'. ..... ,4.......,_1?"-~"-=o ....;._S_.;:;~ .... ( ___ ID// ________ Da te Collec te_d_~___,r,....a,-1~-=--l/.......;;._T_i_·m-e_0_9_J_O __
Type of Sample:
Environmental
Groundwater
Surface Water
✓Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Results mg 1 Parameter Results _mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
Parameter
Endrin
Lindane
Results m /1
Methoxychlor_· ___ _
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury ·-I Selenium
Silver
ORGANIC CHEMISTRY
Parameter
Toxaphene
2,4-D
2,4,5-TP(Silvex) __ _
Comments
Parameter
Chloride .
_ Conductivity
_ Copper
Fluoride
Iron
_ Manganese
Nitrate
_pH
Sulfates
TDS
Zinc
TOC
Petroleum
EDB
TOX
Results m /1
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls _Gross Alpha -(MPN) Coliform Colonies/lO-Omls Gross Beta ------
Date Received V 7---t::f'}L Date Reported _ _..& .......... -._/ ..... f_-_J ___ ( ______ _
Date Ex tracted 0 -/3 ·-J' t/ Date Analyzed_...,.~'---/....,.:(""':-, ~-J.,.,,,::._r'l~:,.,..,;-rB-.-.-£3,.__.£)_.-:;..... __ _
Reported By .· ·--· -~----------Lab Number _______________ _
DRS 3191
Solid and Hazardous Waste
''
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number '!1 ·-oc.'.,Jc,-,,iO{ C-r>Q X Field Sample Number t>Ol 379
Name of Site f>c..a LE Site Location _ ___!,U:;.....,.T...;,.D~.S...,,/J.,__ _____ _
Collected By KA,?wc>Stc/ ID/I ________ Date Collected ,{,(g'{ Time ()1Jt>
Type of Sample:
Environmental
Groundwater
~urface Water
✓soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Comments
Parameter Results mg l Parameter Results mg/1 Parameter Results m,/1 •--=-=------=-=------------.::...=..-'-'-'----1 Arsenic
Barium
Cadmium
Chromium
Lead
Mer1zury
Selenium
Silver
Arsenic Chloride
Barium Conductivity
Cadmium Copper
Chromium Fluoride
Lead Iron ·-··-~~ Mercury
Selenium
Silver
ORGANIC
Manganese
Nitrate
pH
Sulfates
TDS
Zinc
TOC
Parameter Results rag/1 Parameter ReR
-
-
-
-
Endrin
Lindane
Methoxychlor ____ _
Toxaphene
2,4-D
2,4,5-TP(Silvex) ---
Petroleum
EDB
TOX
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter
(MF) Coliform Colonies/lOOmls Gross Alpha
(MPN) Coliform Colonies/lOOmls Gross Beta -
-
-
Results PCi/1
Date Received F 7~
Date Extracted /,,-/ 9-J' </
Date Reported ___ {p_-_,_/~f_-.c...f-'</ ______ _
Date Analyzed_..=.&_·_..:.-/-L/_----=---tf....:.1/ _ _,&"""~c-=c:.._----.--
Rep or ted l3y_
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
La b Number 4 ~,311~J --------------------------
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= pg/ml= mg/1 = pg/g = mg/kg
ppb = pg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number - A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number - 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 ground-
water, surface water or soils which may be contaminated.
Concentrate - A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
• I
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Numb er 13 ··('JCi<;(,c:-!Oc:>t:,X,. Field Sample Number ·'=If :JSA9
Name of Site fl (I(./= Site Location lJ r;o_s/9
Co 11 ec ted By (<A,e -voS>11 IDtl ________ Da te Collec te_d_G_/, ....... i....,q.-=""i"'-L.J,.___T_i_m_e_t,_ct_'i_.S __ _
Type of Sample:
Environmental
Groundwater
Surface Water
7soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Par ameter Results mg 1 Parameter Results mg/1
Arsenic
Barium
Cadmium
Chromium
Lead ,,.,..--~·•: Mercury
Seleni
Silver
Parameter Results rag/1
Endrin
Lindane
Methoxychlor -----
Arsenic
Barium
Cadmium
Chromium
-Lead
Mercury
Selenium
Silver
ORGANIC CHEMISTRY
Parameter Re~u
Toxaphene
2,4-D
2,4,5-TP(Silvex) ---
Comments
Parameter
Chloride
Conductivity
Copper
Fluoride
Iron
Manganese
Nitrate
pH
Sulfates
TDS
Zinc
TOC
Petroleum
EDB
TOX
Results mr/1
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/1
(MF) Colif orm Colonies/lOOmls Gross Alpha --(MPN) Coliform Colonies/lOOmls Gross Beta --
--
--
Date Recei ved _____ 5?L-----'7'----=-£-""'~------Da te Reported _ ___._.&.__--'-J~f.._,,_-_¥_-_¥-__ ~------
_t:}~-/,_,J,c.___,-9~</ ____ Da te Analyzed__./o-'L--.l-/il---r</-,__-..,.,--,.....r ,.;.,Y.-,.-.::~::::..c.~.=...:.._ __ Date Extracted
Reported By __
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
Lab Number -1~731~0
---------------------------
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= µg/ml = mg/1 = pg/g = mg/kg
ppb = µg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Si te Number - A twelve-digit site/location identifier, assigned only
by the district field representative.
Fi e ld Sample Number -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.
Da te and Time Collected -Self-explanatory.
Env ironmental - A sample of a naturally occurring substance such as ground-
water, surface water or soils which may be contaminated.
Concentra te - A sample of a waste, including but not limited to, sludges,
r esins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number Cf .! ·-tt>Of.i{>t:., 1. (/Cc, -A..
Name of Site f c,g LF
Field Sample Number t!> bi ?cg~-
Site Location ~COS J,3
IDff _______ ____:Da te Collec te_d___,:.c_l...,.,-z~k...;;.'1......,..'---T-i_m_e_l_2_1_t> __ Collected By /!1>te1VO!I(.'/
Type of Sample:
Environmental
Groundwater
Surface Water
.,/Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Results mg 1 Parameter Results mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
Parameter Results rag/1
Endrin -Lindane -Methoxychlor -
-
-
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
ORGANIC CHEMISTRY
Parameter Resulrs mo/
Toxaphene -2,4-D -2,4,5-TP(Silvex) -
-
-
Comments
Parameter
Chloride
Conductivity
Copper
Fluoride
Iron
Manganese
Nitrate
pH
Sulfates
TDS
Zinc
TOC
Parameter
✓PCB's
Petroleum -EDB -TOX -
-
Results m /1
Ro,,.,l t-c, ~n /1
~il Pjll.1 r
MICROBIOLOGY RADIOCHEMISTRY
Parameter
(MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls -
-
-
Da te Received F7-~
Date Extracted 67-l<f_-Y=
Reported By
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
Parameter Results PCi/1
Gross Alpha
Gross Beta -
-
-
Da te Reported !e -1-S--J"'-/
Date Analyzed (p -JS--£~ ~£)_
Lab Number 4 ' 31•)<-'-;• ,i.;'-.,}
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e .g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= pg/ml= mg/1 = pg/g = mg/kg
ppb = µg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number - A twelve-digit s i te/location identifier, assigned only
by the district field representative.
Field Sample Number - 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.
Env ironmental - A sample of a naturally occurring substance such as ground-
wa ter, surface water or soils which may be contaminated.
Concentrate - A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number '(] ·-o.:)(",-l:·;io 1 0()0 )(
Name of Site f>c f3 L r: Field Sample Number / 36 Z-
Site Location Vi y ,-en,., C~n
Collected By C irl <'; if}, I'-"
Type of Sample:
ID# Date Collected bl /<?,i Time /0 / 6 ---------I I ...L..c~._:;__
Environmental
\/Groundwater
Surface Water
Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Results mg l Parameter Results mg/1
Arsenic
Barium
Cadmium
Chromium
Lead ~--~~~~~--~~~--Mercury JP''0·;,
-Selen iu ,{ ,f? --------"~
1r-..,
Silver .. ~; tr..,,
Parameter Results rag/1
Endrin -Lindane -Methoxychlor -
-
-
Arsenic
Barium
Cadmium
Chromium -· Lead
Mercury
Selenium
Silver
ORGANIC CHEMISTRY
Parameter Resulrc: mo /:
-Toxaphene
2,4-D -2,4,5-TP(Silvex) z ee::e. <O,l(Jt:>h ,r-
-
Parameter
Chloride
Conductivity
Copper
Fluoride
Iron
Manganese
Nitrate
pH
Sulfates
TDS
Zinc
TOC
Parameter
PCB's -Petroleum -EDB -TOX -
-
Results m 1/l
Roc-,.lt-c m n /1 ,.
MICROBIOLOGY RADIOCHEMISTRY
Parameter
(MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls -
-
-
Date Received .r-7-&-y
Date Ex tra cted <a -Llric./
Reported By
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
Parameter Results PCi/1
Gross Alpha -Gross Beta -
-
-
Date Reported 6'-;st-P 7
Date Analyzed ~ 6-;i. -R ·
Lab Number ·1 ~, 31;2{_;
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm = pg/ml = mg/1 = pg/ g = mg/kg
ppb = µg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number - A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number - 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.
Da te and Time Collected -Self-explanatory.
Env ironmental - A sample of a naturally occurring substance such as ground-
water, surface water or soils which may be contaminated.
Concentrate - A sample of a waste, including but not limited to, sludges,
r esins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number Cf.? -O Of.•"-'P I c,p ,7 )(
Name of Site f' C 6 L f:::.
Collected By G la i-Q 'L, /
Type of Sample:
Field Sample Number / 3 6 3
Site Location /';;-) d t:t::·e-o< ~
ID// _______ Date Collected 6lc,~/2<f-Time JO I!:>...__
I I
Comments Environmental
__iL(;roundwater
Surface Water
Soil
Concentrate
Solid
__ Liquid
__ Sludge
Other
~ ;z ,.,,, e & s 5cJ,,,,'l.fe ff / J6 2
Other
Extractables
Parameter Results mg 1
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Seleni
Silve
Parameter Results rag/1
Endrin -Lindane -Methoxychlor -
-
-,
MICROBIOLOGY
INORGANIC CHEMISTRY
Total
Parameter Results mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
~ Mercury
-. Selenium -Silver
ORGANIC CHEMISTRY
Parameter Res11lrc. ma!
Toxaphene -2,4-D -2,4,5-TP(Silvex)
1 PC, 13 ;-< Q , L ().j)..h r -
Parameter
Chloride
Conductivity
Copper
Fluoride
Iron
Manganese
Nitrate
pH
Sulfates
TDS
Zinc
TOC
Para.meter
PCB's -Petroleum -EDB -TOX -
-
RADIOCHEMISTRY
Re sults m•/1
000,,1 t-~ --/1 ,.
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls -
-
-
Date Received y 7-~Y
>
Date Extracted (a -J/-f'i_
Rep orted By
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
Gross Alpha
Gross Beta -
-
-
Date Reported u --1'/~ri
Date Analyzed 6, -/-2 -?t/ BJQ 1' . -j Lab Number .. •! ~:J .,.. • ,~-1 , '-4.1'-w ~
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= pg/ml= mg/1 = pg/g = mg/kg
ppb = µg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number -A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number - 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 ground-
water, surface water or soils which may be contaminated.
Concentrate - A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number q 3 -lv,:,,019i..::,1 Do O .X Field Sample Number_L/-=3=---""b:.........:L/~·· ____ _
Name of Site P ( .£ LP Site Location l(},1 vVe,-iv C:tJ
Collected By (.; t-2 5 C: ,---IDII Date Collected 0/2;/g Lf Time l /{J-() --------7 I Type of Sample:
Environmental
/Groundwater
Surface Water
Soil
Other
Concentrate
Solid
__ Liquid
__ Sludge
Other
Extractables
Parameter Results mg/1
Arsenic -Barium -Cadmium -Chromium -Lead -
-Mercury
Seleniumrt1{CE/v):,~ -
Silver /_~ ~ -;:::: <-?..1 -:.0:: Qo -~-· a:,, -H,l 1 9 .1-'!/l ID ::c: 'l '· ·p
~I -i~ -~,?~ ... ~,/ -~WASTE ~~~
Parameter Results rag/1
Endrin
Lindane
Methoxychlor ____ _
INORGANIC CHEMISTRY
Total
Parameter Results mg/1
Arsenic -Barium -Cadmium -Chromium -Lead -•. Mercury
-: Selenium -! Silver -
-+
-
-
' -
-
ORGANIC CHEMISTRY
Parameter Re~u
Toxaphene
2,4-D
2,4,5-TP(Silvex) __ _
_z PC-f3 <tJ, lffe
Comments
Parameter
Chloride -
-Conductivity
-Copper
Fluoride -Iron -
-Manganese
Nitrate -
-pH
Sulfates -TDS -Zinc -TOC -
-
Parameter
PCB's
Petroleum
EDB
TOX
Re sults mg/l
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls -Gross Alpha
(MPN) Coliform Colonies/lOOmls Gross Beta --
--
--
Da t e Received _____ j_-=-_7~--~f~Y ______ Da te Reported __ ~&"---~/~<j.-~f.c.-~</ ______ _
Date Ex tr ac ted __ _y{p4-_-L/L/_-_:_Jl_'f,_• _____ Da t e Analyzed __ -=.b__,-/.:_,,,?ij.-.--. --~.,;c1:r..,.,...-,;(-.,-,-.,,,~-_..) /J_.,__,iO.,,,,·~---
Repor ted Tiy ________________ Lab Number ___________ '--_J _____ _
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= pg/ml= mg/1 = pg/g = mg/kg
ppb = µg/1 = ,.ug/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number - A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number - 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 ground-
water, surface water or soils which may be contaminated.
Concentrate - A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number Cf 3 -[?(r:oo , oo 0 )5, Field Sample Number / 3 C ,6 ? 0 -!.....::"--"''--"-'---/-,----
Name of Site (, B L _ f Site Location -ZCJ;:z, y,...,, e,1 1,, ( --0
J /4 / .
Collected By G a Wv ID/I Date Collecte<l-h& /8 L/ Time /3 / .5 --------I l
Type of Sample:
Environmental
-i./ Groundwater
Surface Water
Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Results mg 1 Parameter Results mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
Parameter Results rag/1
Endrin -Lindane -Methoxychlor -
-
-
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Se':)..enium
Silver
ORGANIC CHEMISTRY
Parameter Results mo /
Toxaphene -2,4-D -2,4,5-TP(Silvex)
7 r:.DB <O,i;p.b
-
Comments
Parameter Results m•/1
Chloride
Conductivity
Copper
Fluoride
Iron
Manganese
Nitrate
pH
Sulfates
TDS
Zinc
TOC
Parameter
PCB's -Petroleum -EDB -TOX -
-
R<>c::11lt-c:: moll
MICROBIOLOGY RADIOCHEMISTRY
Parameter
(MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls -
-
-
Date Received J -7 -?Y
Date Extracted {12_-/L-Jl</
Rep or ted By
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
Parameter Results PCi/1
Gross Alpha
Gross Beta -
-
-
Da te Reported (p --1 i -ctY ,
Date Analyzed t--/.:2 --J?V 842
Lab Number ·1 ~ --~» ·.10 •V-Ld
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm = pg/ml = mg/1 = pg/ g = mg/kg
ppb = µg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number -A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number - 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 ground-
water, surface water or soils which may be contaminated.
Concentrate - A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v') the desired parameter to be analyz'ed. 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.
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number Cf 3 -c;,c:oc:-e,; Jo oo .)(_ Field Sample Number-+-/_3-=----=£=--=~::::-_____ _
Name Of Sl. te D <.''. f·:?. L. ~ ) C-C __ l'--J _ !=::._ Site Location //., cU' ( f1/lV /0
Collected By (~ [c;:;J~~ e ,...,, ID/I Date Collected f;/t; /gq Time / /& Q
Type of Sample: ---------r 1
Environmental
✓-Groundwater
Surface Water
Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Comments
Parameter Results mg l Parameter Results mg/1 Parameter
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
Parameter
Endrin
Lindane
Results rag/1
Methoxychlor ____ _
MICROBIOLOGY
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
• Selenium -. Silver
ORGANIC CHEMISTRY
Parameter Resu
Toxaphene
2,4-D
-2,4,5-TP(Silvex)
.J.L f c. r3 < o-, ,-n-nh-
' I
Chloride
Conductivity
Copper
Fluoride
Iron
Manganese
Nitrate
pH
Sulfates
TDS
Zinc
TOC
Pa r ameter
PCB's
Petroleum
EDB
TOX
RADIOCHEMISTRY
Results m1 /l
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls Gross Alpha --(MPN) Coliform Colonies/lOOmls Gross Beta --
--
--
Date Received ____ ~f"'---~7--_~_y _____ Date Reported_--'&u't:J'--~-L-/~t/,__·-~y=--..,y!:__ _____ _
Date Ex tr ac ted __ {a"""-----"-/_,_/_,_;J7=-'~'/--_
7
_____ Da t e Analyzed_....-=!J?_-~/,....,d1.· _ _.,_,f~,__Y___.4~?£2~---
Repor t ecl Dy Lab Number •1 ~, J12~f ----------------------------------
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated .
Equivalent measurements:
ppm= pg/ml= mg/1 = pg/g = mg/kg
ppb = µg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number - A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number -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 ground-
water, surface water or soils which may be contaminated.
Concentrate - A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) the desired par ameter 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.
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Name of Site F C✓ g L. r
Collected By G la ~5-e~r/
Type of Sample:
Field Sample Number / 3 b 7
~
Site Location k/«rl-"t'. f\...-Co
ID/I Date Collected b/6 /(?4--Time / 3 IS J
Environmental
__L__Groundwater
Surface Water
Soil
Other
Extractables
--------7 l
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Comments
Parameter Results mg 1 Paramete r Results mg/1 Parameter Results m 1/l 1--------------""'-'----l Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
Parameter Results rag/1
Endrin -Lindane -Methoxychlor -
--
MICROBIOLOGY
Arsenic Chloride
Barium Conductivity
Cadmium Copper
Chromium Fluoride
Lead Iron
~Mercury Manganese
-.'Selenium Nitrate
Silver pH
ORGANIC CHEMISTRY
Sulfates
TDS
Zinc
TDC
Parameter Resulrc:: ma/ Paramete r
Toxaphene PCB's --2,4-D Petroleum --2,4,5-TP(Silvex) EDB -<'2 ,iRpb -L PCB TOX -7---
RADIOCHEMISTRY
Roc,,1 t-c mn /1
'-
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls -
-
-
Date Rece ived 5 -7 -r,;/
Date Ex tracted (_p -/~-i'-1
Rep or ted By
DRS 3191 (Revised 2/84)
Solid and Hazardous Waste
Gross Alpha -Gross Beta -
-
-
Da te Reported 0 -1 <I-Pt/
Date Analyzed /4 --ii --Y Y v1lQ
Lab Number ·1;, ,·01:11
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= µg/ml = mg/1 = pg/g = mg/kg
ppb = µg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number -A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number -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 ground-
water, surface water or soils which may be contaminated.
Concentrate - A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number q .?-C,[,[>;:-,o f1.,r,t) X Field Sample Number / 3 6 S
Name of Site pc_ B L F Site Location 0 )? t: t: 't'4L ( -r""2
Collected By G i;.::::z 0/ \ , IDII ________ Date Collected t/2/5:p Time /Lf-~O
Type of Sample:
Environmental ✓Groundwater
Surface Water
Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Comments
Parameter Results mg 1 Parameter Results mg/1 Parameter Results m /1 •----------------'"'-'---I Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
Parame ter Results rag/1
Endrin -Lindane -Methoxychlor -
-
-
MICROBIOLOGY
Arsenic Chloride
Barium Conductivity
Cadmium Copper
Chromium Fluoride
Lead Iron
Mercury _ Manganese
-·selenium Nitrate
Silver pH
ORGANIC CHEMISTRY
Sulfates
TDS
Zinc
TOC
Parameter Res11lts ma/ Parameter
Toxaphene PCB's --2,4-D Petroleum --2,4,5-TP(Silvex) EDB
....k.:" l?cli <o,l~b -TOX -1---
RADIOCHEMISTRY
R<:>c,111t-c rnn/1 -=
Parameter Parameter Results PCi/1
(MF) Colif orm Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta --
--
--
Date Received _____ S-:_----"-7----=-~ .... f/c....__ ___ Da te Reported_~~'---'/___,_f_-_J-'~'£_~------
Da te Ex tr ac ted_--'-0_-_,/-",)__---=J'--'--l/ _____ Da te Analyzed_b_-----..--/ ~~--~Y"------'f'----~d'"""-"~ .... '0'-------
19 , •' ll Reported By Lab Number '.t.·.dl_:J'> -------------------------=="""----------
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= pg/ml= mg/1 = pg/g = mg/kg
ppb = pg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number - A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number - 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 ground-
water, surface water or soils which may be contaminated.
Concentrate - A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number q3 -e,,o c,r.:r:> u·,oo X Field Sample Number / 3 t: 9
Name of Site -P c _& L {-Site Location t<Ja 'Yr"e1/l_; C,o
Collected By C r-i ,;.,e_/ l./ ID/I ________ Date Collected Gt/4k lt Time J!/JJ--()
Type of Sample: /
Environmental
V Groundwater
Surface Water
Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Results mg 1 Pa r ame ter Results mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
Arsenic
Barium
Cadmium
Chromium
Lead
_ Mercury
' Selenium ---' ,, Silver
ORGANIC CHEMISTRY
Comments
Parameter
Chloride
Conductivity
Copper
Fluoride
Iron
Manganese
Nitrate
pH
Sulfates
TDS
Zinc
TOC
Results m /1
Parameter
Endrin
Lindane
Results rag/~l:::....i._P~ar!:....::am:::.:::.e~t=e~r __ ~R~e~R..!.!...b..i...;J1Jal..L+..-=-P~a~r~a~m~e~t~e~r ___ -ll..i::..::i.ll.l..J....::'--'-li.g,..I-...J..-t
Toxaphene PCB's
2,4-D Petroleum
Methoxychlor ____ _ -2,4,5-TP(Silvex) EDB ..J.L f D /J <O-,J-1¥11--TOX
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta --
--
--
Date Rece i ved ____ _::,.5;._·_-:...--'-7 __ -_.,f:£.-F-f( ___ Da te Rep or ted __ t_---_,/__,_</_---_y_l/~------
Da te Extrac ted __ /p_--'--/_)_-J'_t/ ______ Da t e Analyzed __ ~_-~/ .... 'J_...-~/..._t/..___~,.1--<1,'1-+Q ___ _
Reported By Lab Number 4 :. .•~~i ''') -----------------------'-'"---''-'·,...,}~~L..Jj.• ~)"=,_),__ ______ _
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
GENERAL INFORMATION
A sample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= pg/ml= mg/1 = pg/g = mg/kg
ppb = pg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Site Number -A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number -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 ground-
water, surface water or soils which may be contaminated.
Concentrate - A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number ~g -0 ot:J,,·,1.>.j f :.>tiO X Field Sample Number ()C> / 170
Name of Si te_-=--P_C~lI~l_F ______________ Site Location lJ ]: l) Sf}
Collected By ((A,twf)SJt'/ ID# ________ Date Collected ,(, lit{ Time t>f'SO
Type of Sample:
Environmental
Groundwater
✓sur face Water
Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Pa r ameter Results mg l Parameter Results mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
Pa rameter Results mg/1
Endrin -Lindane -Methoxychlor -
-
-
Arsenic
Barium
Cadmium
Chromium
Lead
~ercury
Selenium
Silver
ORGANIC CHEMISTRY
Parameter Resul re: ,.,.,,..,./7
Toxaphene -2,4-D -2,4,5-TP(Silvex) -
-
-
Comments
Paramete r
Chloride
Conductivity
Copper
Fluoride
Iron
Manganese
Nitrate
pH
Sulfates
TDS
Zinc
TOC
Para.meter
__Jt!.PCB's
Petroleum -EDB -TOX -
-
MICROBIOLOGY RADIOCHEMISTRY
Results m1 /l
Roc,,l t-c rnn /1
<o. I "'fJ J, r
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta --
--
--
Date Recei ved ___ ---=-j_--'-,)_-_,r---Ly _____ Da te Reported __ ....,67,p;.__-_c__/c/ ......... ·-_....::c?=-----t/'--,.-____ _
Date Extract ed ___ b=-·--~/_J..=--...... x'L.._.C<f _____ Da t e Ana l y z ed __ ....... G?...,.£.,__--~/,...,.'.,J,,.___---=J''---'1/'-----L& ......... ~e---
Rep or t ed By Lab Numbe r 4; i '11'• l ----------------______ .,_u=-==---'-L'-' _,r;..._ ______ _
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
GENERAL INFORMATION
A s ample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e.g., inorganic, organic, microbiology, radio-
chemistry). For sampling conditions which require more than .one (1)
container (i.e., ground or surface water from landfills) a sample label
must be a ffixed to one of the containers. The collector must then write
the site and sample number on the duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= pg/ml= mg/1 = pg/g = mg/kg
ppb = µg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Si te Number -A twelve-digit site/location identifier, assigned only
by the district field representative.
Field Sample Number -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.
Da te and Time Collected -Self-explanatory.
Env ironmental -A sample of a naturally occurring substance such as ground-
water, surface water or soils which may be contaminated.
Concent rate - A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) the desired parameters to be analyzed.
Ex tractables 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 (v) 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.
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number c1.1 ~oc.,r·<.c'J L o c,u ('( Field Sample Number C>o / J 7 /
Name of Si te __ /J_C __ (3 __ t--'-F ______________ Si te Location (J Tl":JS 8
Collected By l<,,4.l<,1\/0 $Kl ID/I Date Collected 6( ,Is. <-f Time c:> er Jo
Type of Sample:
Environmental
Groundwater
✓surface Water
Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Results mg 1 Parameter Results mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
_ Mercury
Selenium
Silver
Para.meter
Endrin
Li ndane
Results m /1
Methoxychlor_· ____ _
Arsenic
Barium
Cadmium
Chromium
Lead
_ Mercury
Selenium
Silver
ORGANIC CHEMISTRY
Parameter
Toxaphene
2,4-D
2,4,5-TP(Silvex) ---
Comments
Parameter
Chloride .
_ Conductivity
_ Copper
Fluoride
Iron
_ Manganese
Nitrate
_pH
Sulfates
TDS
Zinc
TOC
Petroleum
EDB
TOX
Results m /1
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls _Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta ------
Dat e Recei ved _____ s:_-_7_·_F'~>' _____ Da te Reported _____ (e._.__-...,1-'t/----'Y.__Y _____ _
Dat e Ex tr acted (p ~ / J -%" '-/ Date Analyz ed __ .... l?_-.... l-=·,;2. ____ -_,f"--,1/_. ~A--~-=---
Reported By Lab Number ____ ._1_;_1_~ __ (='._i~:~;~;~l ______ _
DHS 3191
Solid and Hazardous Waste
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number 9 l ·-c,o oc~o 1£100 :;( Field Sample Number (!)O I] 7 c
Name of Site_....;f;__c_~.,.,_L..:..F _____________ Site Location u:r:u.s)'.4
Collected By_--i.;K.;.,_A.:.;.,'c;:;__v.;;;;o..::::S..;..K.L..z ____ ID# ________ Da te Collected 6/ ,lw Time o q y ~-
Type of Sample:
Environmental
Groundwater ✓surface Water
Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Re$ults mg 1 Parameter Results_mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
-·_Mercury
Selenium
Silver
Parameter
Endrin
Lindane
Results m /1
Methoxychlor ____ _
Arsenic
Barium
Cadmium
Chromium
• Lead 7 Mercury
-: Selenium
Silver
ORGANIC CHEMISTRY
Parameter
Toxaphene
2,4-D
2, 4 ,5-TP (Sil vex) __ _
Comments
Parameter
Chloride
_ Conductivity
_ Copper
Fluoride
Iron
_ Manganese
Nitrate
_pH
Sulfates
TDS
Zinc
TOC
Petroleum
EDB
TOX
Results m /1
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls _Gross Alpha -(MPN) · Coliform Col~nies/lOOmls Gross Beta ------
Da te Recei ved. ____ --=y~--)_~_~_;:;.._Y-___ Da te Reported __ &,_-_/.___.· ( ___ ~_,f,:....Lf_· _____ _
Date Extracted /0 -/,;} -d Date Analyzed_-'{£?~--L-1t-:r,;z...,.~ -:--~_-f-.'-(-.. -&J,....c.;:~--
Reported By _______________ Lab Number _______ ,_v_ ....... _u~•~u:;_ ____ _
DRS 3191
Solid and Hazardous Waste
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Field Sample Number 00 { J 2:?
Name of Si te ___ P_..;::c_;;..,(5=-.;:;(,..;.f--_____________ Site Location ____ u=-<r-'u:;;-.;s=:..;.;;;IJ ______ _
Collected By_-.a.f::..#,A ..... ~""---,J-==o;.:;S.:...~._I ___ ID/I ________ Date Collected '1U.h~'-I Time o ctL{ S-
Type of Sample:
Environmental
Groundwater
~urface Water
Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Re$ults mg 1 Parameter Results _mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
_ Mercury .
Se1enium
Silyer
Parameter
Endrin
Lindane = Methoxychlor ____ _
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
. Selenium -: Silver
ORGANIC CHEMISTRY
Parameter
Toxap~ene
2,4-D
2, 4, 5-TP (Sil vex) __ _
Comments
Parameter
Chloride.
_ Conductivity
_ Copper
Fluoride
Iron
_ Manganese
Nitrate
_pH
Sulfates
TDS
Zinc
TOC
Petroleum
EDB
TOX
Results m /1
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) ·coliform Col~nies/lOOmls Gross Beta ------
Date Received _____ ,~-_-__:.)_-____ 8':~Y'--____ Date Reported ___ u,,--~_/_(_-_~_-_;/ ______ _
Date Extracted (p -J·'J,--kV Date Analyzed __ &J___.-/_~ __ -_P___..._y' __ ,a-=-w-=----
Reported By Lab Number _____ •~1~:_,~0-r~1➔~,o;'~•,~·, _____ _
DRS 3191
Solid and Hazardous Waste
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number C'('J" Of:,(. Joo , ootJ )( Field Sample Number t!>C') I '1 7 L/
Name of Site Pc [3LF Site Location ,-e.ci),SJq
Collected By====-_J(=,A:R:-,...,_-_o~S~~~/~~~---_-I_D_#~~~~~~~~~~~~~~~=Date Collecte_d_~___,r~b~z~~~y--"--T-i_m_e_/_o_o_o __
Type of Sample:
Environmental
Groundwater
✓Surface Water
Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Results mg 1 Parameter Results _mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
_ Mercury .
Selenium
Silver
Parameter
Endrin
Lindane
Methoxychlor ____ _
Arsenic
Barium
Cadmium
Chromium
Lead
. _ Mercury
Selenium
Silver
ORGANIC CHEMISTRY
Parameter
Toxaphene
2,4-D
2,4,5-TP(Silvex) __ _
Comments
Parameter
Chloride
_ Conductivity
_ Copper
Fluoride
Iron
_ Manganese
Nitrate
_pH
Sulfates
TDS
Zinc
TOC
Parameter
_.Jt{PCB's
Petroleum
EDB
TOX
Results m /1
MICROBIOLOGY RADIOCHEMISTRY
Para.meter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) . Coliform Colonies/lOOmls Gross Beta --
~ ---
Da te Recei ved _____ .::c.r-_-_?_-"""?.,...Y<---,----Da te Reported _ __...&~---_.l'----'✓--.... Y.._</_· _____ _
Date Extracted &P -I 2--g i Date Analyzed_~{a----_L~-=:;~ ........ -4J:' .......... ;/.__-,,,/d"""'"" .. o"---__
Reported By Lab Number ____ ~4......._,:w,•~·1~-1~k~:,~;t5..::t--------
DHS 3191
Solid and Hazardous Waste
N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number qJ -uou1.•/r, i c,o o x Field Sample Number t>D ( J 7 £
Name of Site fc (3 l F Site Location ft..CDS iJ ----=--=...:;::;__ _____ _
Collected By {(ARwo~1c1 ID// ________ Date Collected ,/,/Cf..'t Time {ooo
Type of Sample:
Environmental
Groundwater
~Surface Water
Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Parameter Results mg 1 Parameter Results_mg/1
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
-Selenium
Silver
Parameter
Endrin
Lindane
Results ta /1
Methoxychlor ____ _
Arsenic
Barium
Cadmium
Chromium
Lead
·Mercury
· -Selenium
Silver
ORGANIC CHEMISTRY
Parameter R
Toxaphene
2,4-D
2,4,5-TP(Silvex) ---
Comments
Parameter Results m /1
Chloride.
_ Conductivity
_ Copper
Fluoride
Iron
_ Manganese
Nitrate
_pH
Sulfates
TDS
Zinc
TOC
Petroleum
EDB
TOX
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls _Gross Alpha -·-(MPN) ·coliform Colonies/lOOmls Gross Beta -------
Date Received J--7~-g> y Date Reported u -1 ✓-rY
Date Extracted {<2. -I ;;i -i' i. Date Analyzed e, ~12 -rY &J
Reported By Lab Number -1 :, ...... j "~(~ . d ... > .,
DRS 3191
Solid and Hazardous Waste
... _ .... N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number c13 -0r::,ooo ( oor-, X Field Sample Number t90( J 71,
Name of Site ____ f _L--"[S=--t ..;..F_~ _____________ Site Location >ec osA
Collected By k't91("10S/t1 ID// Date Collecte-d-~-z~,-75r-=-L{--T-i_m_e_l 2_1_o __
Type of Sample:
Environmental
_9roundwa ter
~Surface Water
Soil
Other
Extractables
Concentrate
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Para~eter Re$ults mg 1 Parameter Results_mg/1
Arsenic
Barium
Cadmium
Chromium
Lead = Mercury
Selenium
Silver
par~oeter Results mg/1
I--Endrin
I-Lindane
Methoxychlor_· ____ _
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
ORGANIC CHEMISTRY
Parameter
Toxaphene
2,4-D
2,4,5-TP(Silvex) __ _
Comments
Parameter
Chloride
_ Conductivity
_ Copper
Fluoride
Iron
_ Manganese
Nitrate
_pH
Sulfates
TDS
Zinc
TOC
Petroleum
EDB
TOX
Results m /1
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/1
(MF) Coliform Colonies/lOOmls Gross Alpha --(MPN) Coliform Colonies/lOOmls Gross Beta ---
1= --
Dste Received ______ v.._~_7 __ -__ £~Y_-___ Date Reported __ ~fR..,___-~/-'-(_-~J'~1/;._ ______ _
Date Extracted ___ ~ __ -...... /....:::.)__~--f_,._·__,yr--__ Da te Analyzed_ ...... 1i."lo/F-, ,....,;:,.c.,, f.-1'-,,
1
-~ ..... K.._-""-1/ __ ~/i~'.Afl~--
Re;)ort.ed By _______________ Lab Number ____ ·_, _v __ . __ .L ________ _
}:i-•S 3191
:olid 3nd Hazardous Waste
. ,. N. C. DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH SERVICES
STATE LABORATORY OF PUBLIC HEALTH
P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611
Site Number q3 -C:)c)(),:)(, it) c, O K Field Sample Number 00 ( 1))
Name of Site fc.B <-F Site Location tee us 13
Collected By I! A~41C>S~I IDII ________ Da te Collected t,.[4 /~'( Time 12? 0
Type of Sample:
Environmental
Groundwate r
~urface Wa ter
Soil
Other
Extractables
Concentra te
Solid
__ Liquid
__ Sludge
Other
INORGANIC CHEMISTRY
Total
Par ameter Results mg 1 Par ame t e r Results mg/1
Ar senic
Ba rium
Cadmium
Chromium
Lead
Mercury
Seleni
Silver
Par ameter
Endrin
Lindane
Results rag/1
Methoxychlor ____ _
Arsenic
Barium
Cadmium
Chromium
Lead
Mercury
Selenium
Silver
ORGANIC CHEMISTRY
Par ame t e r Res
Toxaphene
2,4-D
2,4,5-TP(Silvex) ---
Comments
Pa r ameter
Chloride
Conductivity
Copper
Fluoride
Iron
Manganese
Nitrate
pH
Sulfates
TDS
Zinc
TOC
Petroleum
EDB
TOX
Re sults m /1
MICROBIOLOGY RADIOCHEMISTRY
Parameter
(MF) Colif orm Colonies /lOOmls -(MPN) Colif orm Colonies/lOOmls -
-
-
Da t e Received S::--7 -,g V
Da t e Extra cted &---L ;)--t''/__
Reported By
DHS 3191 (Revised 2/84)
Solid and Hazardous Waste
Parameter Results PCi/1
Gross Alpha
Gross Beta -
-
-
Da t e Reported (e -Ji/-tf
Date Analyzed &; -; 3 -~y ;13Z}
Lab Number -1~ <11 1 -· ,· 'l I
GENERAL INFORMATION
A s ample analyses request form (DHS 3191) must be completed for each type
of evaluation requested (e .g., inorganic, organic, microbiology, radio-
chemistry). 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 of the containers. The collector must then write
the site and sample number on t he duplicate.
Do not submit an analysis request sheet with no parameters indicated.
Equivalent measurements:
ppm= pg/ml= mg/1 = pg/g = mg/kg
ppb = µg/1 = pg/lOOOg = pg/kg
DEFINITIONS/INSTRUCTIONS
Si te Number -A twelve-digi t site/location identifier, assigned only
by the district field representative.
Field Sample Number - 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.
Env ironmental -A sample of a naturally occurring substance such as ground-
water, surface water or soils which may be contaminated.
Concentrate -A sample of a waste, including but not limited to, sludges,
resins, treatment effluents or drummed wastes.
Comments -Lists details regarding sample or sample point, including but
limited to, phase separation, and/or odors.
Inorganic Chemistry -Check (v) 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 (v) 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.