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HomeMy WebLinkAboutNCD980602163_19841219_Warren County PCB Landfill_SERB C_State Laboratory of Public Health Field Samples, 1984-OCR, .. 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 Si tC' Numb er 9 3 ·-@() Ooo / ,:;>o v K Field Sample Nurnbev'_O_~,__0-==·:_(/-'---'-/ _____ _ N;J!J1l'. or Si t e /J(!._.{3 L-,1/V.i) /:I '--<-Site Location A r TON . Collec ted By 0b-t ,~IZ-. IDl! __ ...._l..,.3.__ ___ Date Collected )~/tt(r'(Time '°300 ff,\A Type o f Sampl e : Envir onme ntal _k'.:::~Gr oundwa t er Surface Wa t e r Soil Other Extra ctables Concentra te Solid __ Liquid __ Sludge Other Comments t,v1;~ # I INORGANIC CHEMISTRY Total P,1r;1meter Re sults mg /1 Pa r ame t er Resul ts mg/1 Parame t er Arsenic --Ba r ium -Cad mium --Chromium -Lec1d -Merc ury -Selenium -Si lver - - - - - - Pa r amet er Endrin Linda ne Methoxychlor ____ _ MI CROBIOLOGY - - - - - - - - - - - - - Arsenic Chloride ·-Barium -Conductivity Cadm i um -Copper Chromium Fluoride -Lead Iron -Mer c ury -Mangane se Seleni um Nitr ate -Silve r -pH Sulfa t es -TDS -Zinc -T0C - - ORGANIC CHEMISTRY RADIOCHEMISTRY Results mg /] Parame t er Parameter Results PCi/1 (MF) Coliform Colonies /lO0ml s Gross Alpha --(MPN) Colif orm Colonies /l00ml s Gross Beta -- -- -- 1);1 tc Rv CC j ve.d_.,.L;_;;___,--/:__c)----"'y=-· IL.( ~&=~=,.__ __ Da t e Re ported / cl_ -; 2 -a ____ _ Di! Le Lx Lr a c t ed--L/.~~',)..,,......r<,_1 J',,,__·_---=-P__,_t/--.,lbr3,~iu-O.__ __ Da t e Analyz ed __ /._d--,.4-,_~-,-'i\~=·-r-,◄.--£~0r-Y_:.,,8.=W)c=-__ _ Rcp.,r l ed By _ Lab Number · ·'' ..A.(Jl'L-7 ----1.--H--¥-~-==-------------------------- OH S 3191 (R evised 2/84) Solid a nd 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/ 1000g = 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, 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 Chem.istr.y -Check (v) the desired parameter to be analyzed. If not listed, 'ent~r •the-'name in the space_ p~ed. { "';"- Microbiology and Radiochemistry -The Ra~eigh .6ffice should be consulted prior to sampling for either of these. ,. -. ' .. N. C. DEPARJ'MENT OF HUMAN RESOURCES DIVISION OF HEALTH SERVICES STATE LABORATORY OF PUBLIC HEALTH P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611 Field Sample Number r:x:;/&-(.O SitC' Number /f3-(2 000 0/000 )( ---------- N:rna.~ or Site f cJJ vANl>f tLL-Site Location A P ro Al Collccted By {:J~ A'S" f-12--ID# / 3 Date Collected /..'l/11/.P ~ime ~30 P~, j ~· Ty p1..: of S,1mple: Environmental ,/(;roundwa t er Surface Water Soil Other Extractables Concentra te Solid __ Liquid __ Sludge Other Comments JJ'Gu.-# ~ INORGANIC CHEMISTRY Total P:1r;tme t e r Re sults mg/l Parameter Results mg/1 Parameter Arsenic -Barium -Cadmium --Chromium -Lead -Mercury -Selenium -Silver - - - - - - Parameter Results rag/1 Endrin Lind_ane Methoxychlor ____ _ MICROBIOLOGY Arsenic -Barium -Cadmium -Chromium -Lead -Mercury -Selenium -Silver - - - - -- - ORGANIC CHEMISTRY Parameter Resu Toxaphene 2,4-D 2,4,5-TP(Silvex) --- - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC Petroleum EDB TOX RADIOCHEMISTRY Results m~/1 Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha --(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- D:1 t c Rl', c j ved_~,/4-~_-...... /_tl,_-_f..__</~~/J,=-W}_· ____ Da te Reported /,,2 -/ 7-::L__,,_1/. _______ _ D;t L c J-:x tract ed~/.~~..,.__._,-4(",,---'-L"'----'-</~,6."'-'--''il)=------Da t e Anal y z ed-----'/_,;l_-/'---L_z _-_..,_cf/_V--.c:,adJ:,,e:;::::.. __ _ Rl'p•, r L1..:d By ___ --'~>..lc---,'-lr-J!l---"_=--..___ _______ Lab Number ____ ___._A,._1.._~.,...-◄_1,'-l-0,_ ______ _ ':t -l...t.. ~9 DH S 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= µg/ml = mg/1 = pg/g = mg/kg ppb = µg/ 1 = ,ug/ 1000g = )lg/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(~) the desired parameters to be analyzed. txtractables 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 ~th~ 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 S i t(• Number _t}L-3=-· _-_:;o:,_o.::......:::o_o.:::.....:,,Q~/-O_o_o_x:...__ ______ Field Sample Number___,;ctl.c....:· :::.....:,_V .;:_63.=-1,9 ____ _ N :1 mli o f Sit e_-+-f)_c,,..__,,,.i'---=~c....:A----'--'-N.....,l)'----'f~t_L-_L_.-________ S i te Loca t ion __ A~E-c'---'-....:o:.__ll)c...::.... ______ _ Co l.l ec ted By Gl-AS€:A--IDll_--1-/.=3 ____ Date Collected J.J./;I Irr Time /DOf m Ty pt.: o f Sample : ~.lr onmental Gr oundwater Surface Wa t er Soil Othe r Extra ctables Pnr;une t c r Re sults Arsenic -Ba r i um -Cadmium --Chr omium -Lead -Mercury -Selenium -Silve r - - - - - - Concentra te Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total mg/1 Pa r amet e r Results mg/1 Arsenic -Barium -Cadmium -Chromium -Lead -Me r cury -Selenium -Silver - - - - - - ORGANIC CHEMISTRY Comments Pa r ame t er Re sul t s ml!/1 Chloride - -Conductivity -Copper Fluoride -Iron - -Man ganese Nitrat e - -pH Sulfates -TDS -Zinc -TOC - - Pa r ame ter Endrin Li nd a ne Re sults rag/1 Pa r ame t er Resu ·-=--1---~.c...:......::....:....::....:.. __ ___._,~'-"'-"""~'-il ......... -+--=-~==c-=:..;;;..:'------"~~'--½':l-.L"+,,'z-'-I Toxaphene - - - - Methoxychlor ____ _ 2,4-D 2 ,4,5-TP(Silvex) --- Petrole um EDB TOX MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter (MF) Coliform Colonies /lOOmls Gross Alpha (MPN) Coliform Colonies/lOOmls Gross Beta - - - Results PCi/1 D:1 tli Rvce .i ved_~/-=,;J'---.......c.../_,~,::___-_.,_f--'-c/_..,,,·M.e;__:=----Da t e Reported /,;2.. -/ 7_ -d._ _____ _ lb t C Ex tr a c ted---"-/.-~..,,..--=;.,tefc_--=i:Y__._Y_, ...=L3:::._'J../)-=---__ Da t e Ana lyzed_/_,;;i_· ---"--1-,t,2,-,.-~Y~Y~~~~----'--tf•' ) ..... ◄ tf Rl' P" 1-LL'.d l~y ----\--A~--==:;..__ _______ Lab Numbe r _______ ·_._,_ ..... _______ _ OH S 3191 (Revised 2/84) Solid a nd Hazardous Waste GENERAL INFORMATION A s ample analyses r equest form (DHS 3191) must be completed for each t ype of evaluation requested (e.g., inorganic, organic, microbiology, radio- chemi s try). For sampling conditions which require more than one (1) conta iner (i.e., ground or surface water from landfills) a sample label mu s t be affixed t o 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/ l = pg/ 1000g = /lg/kg DEFINITIONS/INSTRUCTIONS V f:::i jQo . JAN 7 198 Si t e Number - A twelve-di git 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 a nd Time Collected -Self-explanatory. Env ironmental - A sample of a naturally occurring substance such as ground- wa te~, surface water or soils which may be contaminated. Concentra te - A sample of a waste, including but not limited to, sludges, r e sins, 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\ entLr the name in the space provided. Microbiology and Radiochemistry -The Raleigh office should be consulted prior to sampling--for either of these. ' . 1 ' .. N. C. DEPARTMENT OF HUMAN RESOURCES DIVISION OF HEALTH SERVICES STATE LABORATORY OF PUBLIC HEALTH P. 0. BOX 28047 -306 ~-WILMINGTON ST., RALEIGH 27611 Site• Number (}3-0oc:u:::,O /Q Oo l( Field Sample Number {)0/(;;3<f N ;1111e () r sit C P c B t /}JV t) rt '-'-site Loe at ion _ ___:Ae,__cF_,_72::,_0,:_/'_J ______ _ Co llected By G,L--A,s-~/<..... ID/I 13 Date Collected i~/2,IP/ Time )loo atv, ---'-'=-------~ I Typ<.: of Sample: Environmental ~;roundwa t e r Surface Water Soil Other Extractables Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total Comments P;ir;1metcr Results mg/1 Paramete r Results mg/1 Parameter Results mg/ 1 Arsenic Arsenic Chloride ----13arium Barium Conductivity ---Cadmium Cadmium Copper ----Chromium Chromium Fluoride ---Lead Lead Iron ---Mercury Mercury -Manganese --Selenium Selenium Nitrate ---Silver Silver pH ---Sulfates ---TDS ---Zinc ·---TOC --- --- ORGANIC CHEMISTRY Parameter Endrin Lind,rne Results rag/,-=.l-+--_P=--=.a~r=am=e~t~e~r __ ~R~e~~~uc.W..,i;2_..l.!.!,,,-L...l,f---:...:...=~=~:...c.._---...J,l,,,lrJ...W7"'-~"+Y Toxaphene - - - - Methoxychlor ____ _ 2,4-D 2,4,5-TP(Silvex) --- Petrole um EDB TOX MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter (MF) Coliform Colonies/lOOmls Gross Alpha (MPN) Coliform Colonies/lOOmls Gross Beta - - - Results PCi/1 1);1 tt: I{(• C(~ .i v e d_~/-~, ---+1-':i.=--_..,.,f--4,..V__,./-i.---'='J'--__ Da te Reported /42 -/7 -r st _____ _ D;i l t: Ext r ac ted_/_71_,,,._+'Vl~...,,..~ J'_A~_P---''/~;rBc...=.-.aJ ___ Da t e Analyzed /c) _ 1 'f-tf',</a ,(J) RL' P" ,-L<.:d By ___ \c-~---,L£J.!l.._,___..__ __________ Lab Number 4., )7106 OHS 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) conta iner (i.e., ground or surface water from landfills) a sample label mus t 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/ 1000g = )lg/kg DEFINITIONS/INSTRUCTIONS Si t e Number - A twelve-digit site/location identifier, assigned only by the district field representative. Fie 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 t e and Time Collected -Self-explanatory . Environmental - 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, r es ins, 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 -~heck (v) the desired parameter to be analyzed. If not listed,, ent'er: the name in the space provided. Microbiology and Radiochemistry -The Raleigh office should be consulted prior to sampling for either of these. ' r 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 Si t C> N 11mb e r __ ~9r....;3=---Jee?:...:o::::.~ _,6,c_,:;O_'C).,..____,/'---"1//<LW=-.:bi>:::..__..e.X~-----F ield Samp 1 e Number l O O / fo3 -Z) N:1 111e or Sit e_--1--e_,e-aeo.....,/j'"'---=l,"-'-"&"'"'M"--:O""-"r.'---"-I _LL-=· ;..__ ________ Site Loca t ion _ __:.A-_F......:;..;TO::..· /V'--------- Collected By Cfwt:iL+QW Typ l: of Sample: IDl/ __ ~_~ _____ Da te Collected fi$Llf;:ef Time / 3d />/YJ Environmentnl Gr oundwater Surface Wnter Soil A ther Extractables Concentra te Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total Comments fl $" t: tJ I /1-te-l/J L Prtr:1meter Results mg/1 Paramete r Results mg/1 Parameter Results mg/] Arsenic Arsenic Chloride ----Barium Barium Conductivity ---Cadmium Cadmium Copper ----·chromium Chromium Fluoride ---Lead Lead Iron ---Mercury Mercury -Manganese --Selenium Selenium Nitrate ---Si] ver Silver pH ---Sulfates ---TDS ---Zinc ·---TOC --- --- ORGANIC CHEMISTRY Parameter Endrin Lindane Results rag/~l.::..+_P~a:::..::..ra~m=e~t~e~r __ ~R~e~s~uc.Ll.,i;l._..l.!!J.i,L.1,f--.,:...::;;.z==:--=:...!..----..J.U::.;::uP--:!:-'='-~4+-4 Toxaphene - - - - Methoxychlor ____ _ 2,4-D 2,4,5-TP(Silvex) --- Petroleum EDB TOX MICROBIOLOGY RADIOCHEMISTRY Parameter Pa rameter (MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta - - - Results PCi/1 D;1 t c Rec cd ved_--'c_.::::..-..1-.::::..:._-=-__.:__~~~---Da t e Reported / ;J. -,:;._ j.-j/ V Da t C Extra Ct ed _ _,__::....:....,~~"-----"f..Jl.'.__~----Da t e Ana l y z e d _ _,_J....:.:J __ -_2-___,J::..___-..... t◄_v:~:A~:L,W)-~~~~~~~~~ ·----½-R---',--==--------Lab Number ______ 4_._· .... ')'--'7.__.1.._0~5...._ _____ _ DHS 3191 (Revised 2/84) Solid and Hazardous Waste GENERAL INFORMATION A sample analyses r equest form (DHS 3191) must be completed for each t ype of evaluation requested (e.g., inorganic, organic, microbiology, radio- chemi stry ). For sampling conditions which require more than one (1) c onta iner (i.e ., ground or surface water from landfills) a sample label mu s t be affixed t o one of the containers. The collector must then write t he 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 = }Jg/1 = pg/lOOOg = pg/kg DEFINITIONS/INSTRUCTIONS AN 7 1985 Si t e Number -A twelve-digit s ite/location identifier, assigned only by the dis t rict 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 Loca tion -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- wa ter, surface water or soils which may be contaminated. Conce nt r a 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. txtractables 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-,, ent~r 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 s i t (' Numb(._' r __ _;;_r.;_d'_-_O_O_O-=Q,:;;_0>..::;.__,/<--=:0....co::...=o;;.__;;_X_.__ _______ F ield Sample Numbe r _ __,:_o.,:_o+-/=b.c....3_fo ___ _ N :11nti () r sit e_➔f--=-&~$"'--~L:""'--"A_.._,.__fvc....lJ""--'£--'-1_L--_'-__________ s i te Loca t ion _ __.:_g;µ7:'-----'''-'f-7.>-~--=· ;..__ _____ _ C:ol.lccted By <Jtvl/U () Jv IDtl_--'2=.i-=-.----Date Collected 1'1/l~b'( Time Type of Sample : Comments Environmental Groundwater Surface Water Concentrate Solid __ Liquid __ Sludge Other ~c., u ,;-II Sc1J1 Me:N, -~i.l \,./'O ther Extractables Pnr;1metc r Arsenic -13arium -Cadmium --Chromium -Lead -Mercury -Selenium -SiJver - - - - - - Parameter Endrin Lindane Results mg/l Results rag/1 Methoxychlor ____ _ MICROBIOLOGY INORGANIC CHEMISTRY Total Paramete r Results mg/1 Parameter Arsenic -Barium -Cadmium -Chromium -Lead -Mercury -Selenium -Silver - - - - - - ORGANIC CHEMISTRY Parameter Re~u Toxaphene 2,4-D 2 ,4,5-TP(Silvex) --- - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC Petroleum EDB TOX RADIOCHEMISTRY Results ms.!/1 Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- D;1 t e Rc cc .i ved _ ___.__/,_~--'----L/_,~__._----=-f _'/.:....· ~A.,,__iJJ ___ Da te Reported /4).., -2-cJ r--1.1_-'<---. _cj ___ _ D;i l c Ext r ac ted-t~~---r~-Ao----=-O"_v_..c...f...L./J ___ Da t e Analy z ed_/_;>._-_;)-~7_-~r~y__,&Q""""-"-~· ___ _ Re P" r Lu l By _____ ~ __ _,_,//~ '--'-==---------Lab Numb er _____ 4~•~• ~_.,..._,_1,~0~4-______ _ OHS 3)91 (Revised 2/84) Solid and Hazardous Waste GENERAL INFORMATION A sample analyses r equest form (DHS 3191) must be completed for each t ype of evaluation requested (e.g., inorganic, organic, microbiology, radio- chemistry). For sampling conditions which require more than one (1) conta iner (i.e., ground or surface water from landfills) a sample label must be a ffixed t o 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 = }Jg/1 = pg/ 1000g = pg/kg DEFINITIONS/INSTRUCTIONS AN ? 19 Sit e 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, 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, entei · .,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 Si tc N11mber lf3 -Oo o t)O I() o C)( Field Sample Number_O--'O'--'~-{p_J_~------ N:1mc of Site fu ll}/fJ/),F1L-L Site Location AFTON ---=---'---'---------- C: o l. le ct e d By '>W,9LC-{JJt) IDII ;;9 Date Collected )~//!/.?}( Time /07) f>/11 I I Type of Sample : Environmental Groundwater Surface Water Soil ~her Extractables P;ir;t1netcr Results Arsenic --Barium -Cadmium --Chromium -Lead -Mercury -Selenium -Silver - - - -- - - Comments Concentrate Solid __ Liquid __ Sludge Other 1/C.t)S O S'E-OIJUEAJr INORGANIC CHEMISTRY Total mg/1 Parameter Results mg/1 Parameter Arsenic Chloride --Barium Conductivity --Cadmium Copper --Chromium Fluoride --Lead Iron --Mercury -Manganese -Selenium Nitrate --Silver pH --Sulfates --TDS --Zinc --TOC -- -- ORGANIC CHEMISTRY Results mi..:/] Parameter Endrin Lindane Results rag/~l=-+_P~a=-:..ra=m=e~t~e~r __ ~R~e~s~u..L!...>2-..1J..t,,;,.1....,1f-.=-;,t::..::::=.::~c.:_---J.u:;..:ilr'::'_.:,._;JJJ./<rl:-~ Toxaphene - - - - 2,4-D Methoxychlor ____ _ 2, 4, 5-TP (Sil vex) Petroleum EDB ---TOX MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter (MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta - - - Results PCi/1 1);1 t C R('C(: j ved _ __c_lc__c:_~_-_,_/,J""''--~flJ.---J</~s..£~~,e__---Da t e Reported J,). -;;i..% -d' _ _._,V ____ _ D;i l c Ext r ac ted__,/fi'-"'·.,_.~9---F----'0=-· __ -_,to£....L.1/_: --LV2.)..l-=--___ Da t e Analyzed_~/~,;}--_~~7_-_tf__,_l/_/-3~£)....__ __ _ Rl' pt,,-Led By ____ _,y-""--,41/i..~..:;.... 1/L._,-===---------La b Numbe r ____ -.J.4-l-'•;_,)o117,-1-t--l01-h3~------- OHS 3191 (Revised 2/84) Solid and Hazardous Waste GENERAL INFORMATION A sample analyses r equest 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 mus t be a ffixed t o one of the containers. The collector must then write t he 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 = ,ug/g = mg/kg ppb = µg/ 1 = pg/ 1000g = JJg/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. Co l l ected 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- wa ter, 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. t x tractab les 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, .ienter ;the name in the space provided. Mi crobiology 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 N 11mbc r __ ~tf...,'J,<.__~fJ.....,Q'--"O~o~Q,;..,,1--L ..... @:..:::0c....O.:;:......,kC..!· ________ Field Sample Number QCJ / {/3'-( N:1111l' () r sit e _ _,_/!...,,c.,,::::./J..,__---"'l,..:..A,~M-""l)C...:F_,_1 '-_'--;:___ __________ site Loe at ion _ _.A"-LLP__,_'[O___;IV:...e..__ ______ _ Col 1 cc ted By_--'-2"""Wli.,_._._.L-L-~_..Q'-"W'-=-----IDt/ __ Q-___ ;;l._3 ___ Da te Callee ted / J /2'/~ Time / 00 f}/J,'; Type of Sample: Environmental Groundwater Surface Water Soil ~her Extractables Par:1meter Results Arsenic -13arium -Cadmium --Chromium -Le;id -Mercury -Selenium -SiJver - - - ·- - - Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total mg/1 Paramete r Results mg/1 Arsenic -Barium -Cadmium -Chromium -Lead -Mercury -Selenium -Silver - - - - - - ORGANIC CHEMISTRY Parameter Results rag/1 Parameter Re~u Endrin Lind,rne Methoxychlor ----- Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Comments f'GIJ1M£AJ, Parameter - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC Petroleum EDB TOX Results ml!/ 1 MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha --(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- D:1 t l' Rl'ce i ved _ ___L/,_b?--"----J./--=-·,;_::_c::__-_.f'---L/-"'°'&R=-=----Da te Reported /). -..2 ~ -J' _ ___,f_· ____ _ D;i t c Ext r ac ted_~~~-~'-"0:-c.._-_8:~t/_.L.V--=-/J-"---__ Da t e Ana lyz ed_~J~,)~--.;i.~7_-~f_,t/'----...... E~/;J)=· ~-- RL' p< q -Led By ----->~~~-----------Lab Number ____ _,4~:_,,).__7L-<1--=-0:....,2'-""-------- OHS 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 ~ ::x: JAN 7 y-· 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. Concentra te - 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. txtractables 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 S i t c• N 11mb e r _ ____.9--=:J.=----...,.f)'--O:...._o....;_o_o--'--1 _()_d_o__;:)(c..:........ _________ F ield Sample Number 00 / b,:53 N;1mc or Site p~,,.4 J.ANI) 1-::'11.--t...-Site Location_--"'/4..J..-L.E-.79--=.:.W-"--------- C:o l lected By "i'W71LUW IDll __ ~ __ :;)3 ____ Date Collected )~/21/Pl/ Time 11:SO ;1/l,f TypL: of Sample : Environmental Groundwater Surface Water Soil i.,26ther Extractables Pnr,t1neter Results Arsenic ---Barium -Cadmium --Chromium -Lead -Mercury -Selenium -Si]ver - - - - - -- Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total mg/1 Pa r ame t e r Results mg/1 Arsenic -Barium -Cadmium -Chromium -Lead -Mercury -Selenium -Silver - - - - - - ORGANIC CHEMISTRY Parameter Results rag/1 Par ameter Re~u Endrin Lind,me Methoxychlor ____ _ Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Comments S'ctJ1 /1--(-£-,,Vr- Parameter - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Man ganese Nitrate pH Sulfates TDS Zinc TOC Petrole um EDB TOX Re s ults mg/] <Clh I iJJ)hl I I MICROBIOLOGY RADIOCHEMISTRY Para me ter Pa rameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha --(MPN) Coliform Colonies /lOOml s Gross Beta -- -- -- D,1 t c Rl ·c c j ved __ f._'e}_-_;__/_;__,;}_-___,J"--•'...:../_....,.&~~=-----Da te Reported /,) -2 J' .-f'i"---,___f ___ _ D;i l t: J·:x l r ac ted~/ _ _2 ~--~-""-0_· ~--'€-....:..'l---0.V.__,_/J ____ Da t e An a lyzed_--+/,""---',)"'-.-:i;)Ti:aa17:-_f--.-~-%°"'1.,,,__(/~'-"""'~'i.f)'------ R l' P" 1-LL:cl 11y -----1~....--J.~~---=='----------La b Number ____ • _4_'_)_7_~ __ o_jr ___ µ_i ____ _ DHS 3191 (Revised 2/84) Solid and Hazardous Waste GENERAL INFORMATION A sample analyses r equest form (DHS 3191) must be completed for each t ype of eva luation requested (e.g., inorganic, organic, microbiology, radio- chemi s try ). For sampling conditions which require more than one (1) conta iner (i.e ., ground or surface water from landfills) a sample label mus t be a ffixed t o one of the containers. The collector must then write the site and sample number on the duplicate. Do not s ubmit an analysis request sheet with no parameters indicated. Equivalent measurements: ppm = pg/ml = mg/ 1 = pg/ g = mg/kg ppb = µg/1 = pg/lOOOg = ]Jg/kg DEFINITIONS/INSTRUCTIONS AN 7 Sit e Number - A twelve-digit site/location identifier, assigned only by the dis trict field representative . Fi eld 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- wa ter, 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. Ex tractables are only perf ormed on a solid or semi-solid. For routine landfill samples, check all parameters in the second and third columns. Organic Chemistriy -Gheck (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• N11mber 9S-'06ooo/OO-e, .,f' Field Sample Number IJO!b's;J___ N:11nli ol Site f>e-,B i--1,}/D,D P:tl-'-Site Location_J..A-...1-..:P__._T'_O_N_· ______ _ Co 11 cc ted By 9/ISIILA--cw IDll __ <_i_~_-;;l.3=-=:;__ __ Date Collected )cJ_/2,,IPJ{ Time /ISO /7141 Typ<.: of Sample : Environmental Groundwater Surface Water Soil ~her Extractables Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total Comments Sc-/J JM{;;NT Par;1metcr Results mg/l Parameter Results mg/1 Parameter Arsenic --Barium -Cadmium --Chromium -Lccid -Mercury -Selenium -Si] ver - - - ·- - - Parame ter Results rag/1 Endrin Lindane Methoxychlor ----- MICROBIOLOGY Arsenic -Barium -Cadmium -Chromium -Lead -Mercury -Selenium -Silver - - - - - - ORGANIC CHEMISTRY Parameter Requ Toxaphene 2,4-D 2 ,4,5-TP(Silvex) --- - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc T0C Petroleum EDB T0X RADIOCHEMISTRY Result s mg/1 Parameter Parameter Results PCi/1 (MF) Coliform Colonies/l00mls Gross Alpha --(MPN) Coliform Colonies/l00mls Gross Beta -- -- -- 1);1 t l' R l' (' C j V e.d_-L.;_;,i_--L-1--""· .).=--=----'r"---S-'-l_·8.=-..,'&e::::.__ ___ Da t e Re pot ted /.;l. -2-i.:..,.f'--'ICc-_ ------ D;1 l e Extra c ted~/.--=-~tp-_ =-~/J--__,~,c_--'-'i--'-V.~/J ___ Da t e Ana 1 y z ed----1'/--=-.)_-;L~Z---:-='J}~'-/,,--:,8.~'A)=---- Lab Numb er , 4.•:J ... ,""100 Rl'\J<l l-Lt:d By --___ _,.,.fd=-E=-'""""'------------------------- DHS 3]91 (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 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. Fie 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. Environmental - 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, 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. txtractables 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 Si t C' N 11mbe r ___ J.9:::::':7'----"0"'-'o=--=o_,0>""'-"'o.._.../ ""'o-"o~o=--~><.,,,_ _______ Fie ld Sample Number /JO / /o3 { N;Jllll'. () r sit e_f1,___c-=~'----'l,c....;..._A,.z.../J.c..c/)~F_,c...LL-="------------s i te Loca t ion _ __;_A-=---r_r_c_-v _______ _ C:o 11 ec tee.I By 9vJ"9 U.....Oli/ ID# ~J Date Collected J.2./11 /& Time /l oo (:Jlt--1 ---=----'-<.-=-~-----=------r I Type of Sampl e : Environmental Groundwater Surface Water So il 7other Extractables Pnr;1meter Result s Arsenic --Barium -Cadmium --Chromium -Lead -Mercury -Selenium -Si]ver - - - - - - Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total mg/l Parame t er Results mg/1 Arsenic -Barium -Cadmium -Chromium -Lead -Mer cur y -Se lenium -Silver - - - - - - ORGANIC CHEMISTRY P.-irameter Results rag/1 Par ame ter Resu Endrin Lind,rne Methoxychlor ____ _ Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Comments J' z:...4; µ, &Al[ Paramete r - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Mang anese Nitrate pH Sulfates TDS Zinc T0C Petroleum EDB T0X Results m~/1 MICROBIOLOGY RADIOCHEMISTRY Parame ter Parameter Results PCi/1 (MF) Coliform Colonies/l00mls Gross Alpha --(MPN) Coliform Colonies/l00mls Gross Beta -- -- -- !);1 t c Rvcej ved ___ /_·.A_-.L.../~,).-~ ... J'_,f----,--'--'8=--~---Da te Reported_-'-/_)_-_2......,J'_-__ ·JJ.-'<j__'--------- Da t C Ex l r ac t ed_/~;l._('?"'~---~.,...c-O_-----""-~-;;-___.Y......,/V'--___ Da t e Analyzed~/_,}._· _-..,..,1---'!'-¼ill-"';:u&'k-,;_J .... v~· .... 6~-,{...,.Q=------ Rl' P" 1· LL:d l\y ____ ...::·""~#=""'J!L_,._'----==--------Lab Numb er _________ J9 _______ _ OH S 3]91 (Revised 2/84) Solid and Haz ardous Waste GENERAL INFORMATION A sample analyses r equest form (DHS 3191) must be completed for each t ype 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 mus t be a ffixed t o one of the containers. The collector must then write t he 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 Numbe r - 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- wa ter, surface water or soils which may be contaminated. Concentrate - A sample of a waste, including but not limited to, sludges, r e sins, 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 Field Sample Number Ool6SO SitC' Number <J.5-06/J t?(>/(2()0 J'. N:1111e of Si tc flc4 l..,4,<J.{) Ft'--L---Site Location __ LA~E-"-7""..:...;.N..:._ ______ _ Coll cc ted By (}l<)_ftt.,-(..,(})J ID# ::ff> :23 Typt: of Sample: Date Collected z~,/(1/'lsf Time j{OO l!M Environmental Groundwater ~urface Water Soil t----eft: he r Extractables P,1r:1meter Results Arsenic --Barium -Cadmium --Chromium -Lead -Mercury -Selenium -Si]ver - - - ·- - - Concentrate Solid ___ Liquid __ Sludge Other £,,<.T/)S 1 INORGANIC CHEMISTRY Total mg/1 Paramet e r Results mg/1 Arsenic -Barium -Cadmium -Chromium -Lead -Mercury -Selenium -Silver - - - - - - ORGANIC CHEMISTRY Comments Sc./)1Mc/VT Parameter Chloride - -Conductivity -Copper Fluoride -Iron -Manganese -Nitrate - -pH Sulfates -TDS -Zinc -TOC - - Results m~/1 Parameter Endrin Lindane Results rag/1 Parameter Resu •_;:;_4---=-.::...::...=-=-=--=-=---~""--""..l.!...c.,._...,'---il~+__:_...:::...::::z:''-";--=:...:;_:------'-~~~::i....J.u+'ri'-'--j Toxaphene - - - - Methoxychlor ----- 2,4-D 2,4,5-TP(Silvex) --- Petroleum EDB TOX MICROB IOLOGY RADIOCHEMISTRY Parameter Parameter (MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta - - - Results PCi/1 1);1 t c Rl' cc .i ved _ __,/.~';.)'-' _-__./'-=-,J_-......,J?_.L..Y_..&e.c...:~=------Da t e Reported----,,_/~~--..c....)..._'9_--"f __ lf-L--,------- D:t t c Ext r ac ted--+-/""".)-~_.:;_)-~a_--><---· __._'-~(l,"--L>V"---___ Da t e Analyzed~i,-~--~~-7~-...,f~<-/~.,....A....,__..J.{}-=· ___ _ 4 ·.~7Qt1JJ Re p1, r Led By ____ ..,_,,~--L--==---------La b Number _________ ..J_u ______ _ OHS 3)91 (Revised 2/84) Solid and Hazardous Waste GENERAL INFORMATION A sample analyses r equest form (DHS 3191) must be completed for each t ype of evaluation requested (e.g., inorganic, organic, microbiology, radio- chemistry). For sampling conditions which require more than one (1) conta iner (i.e., ground or surface water from landfills) a sample label mus t be a ffixed t o one of the containers. The collector must then write the s i te 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 = /Jg/kg DEFINITIONS/INSTRUCTIONS Sit e Numb er - A twelve-digit s ite/location identifier, assigned only by the distri ct field repres entative . 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 Tim e Collected -Self-explanatory. Environmental - A sample of a naturally occurring substance such as ground- wa ter, surface water or soils which ma y be contaminated. Concen t r a te - 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, eritei 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 fa Si tc· N umbe r ___ 9.......::i3_-...c.o_0_,_4'_.s__.._/_O_o_o__,X..,__ _________ F ield Sample Numb e r_OO_.__;./....;f;;__~_· a_..( _____ _ N:irn e or Site ee~ L-4/!W r /L-.1-Site Location AE TQA/ C:ol lected By 0rif?Tc/?-IDtl __ ;?.-==G'-------Date Collected J.:). 1 /11,/?l(' Time ~/ 30 f for Type of Sample : Comments Env .i ronmen tal Groundwater -----S urface Water Soil Concentrate Solid __ Liquid __ Sludge Other If'.{',,, us 4 µ,,,. ~~-S' ~L,f:;- Other Extractables P ;i Lnne t er Results mg/1 Arsenic ---Ba r i um -Cadmium --Chromium -Lead -Mercury -Selenium -Si]ver - - - - - - Parame ter Results rag/1 Endrin Lind,me Methoxychlor ____ _ MICROBIOLOGY INORGANIC CHEMISTRY Total Parameter Results mg/1 Parameter Arsenic -Barium -Cadmium -Chromium -Lead -Mercury -Se lenium -Silver - - - - - - ORGANIC CHEMISTRY Parameter Re~u Toxaphene 2,4-D 2,4,5-TP(Silvex) --- - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC Petroleum EDB TOX RADIOCHEMISTRY Results mg/1 Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- ILi t c Rc cc .i ved_----'-/.-~_---L/___:;J_-_.f,_Y~/3~'£/=---___ Da t e Reported /4) -/ 'j' -f </ ______ _ D;i L c Ex t r ac ted_-+/"""',,2-~..,,,,.--. -. _-...,.Y~½-=g...e:'IJ)::.-=--__ Da t e Analyz ed _ ___,_/_.2:,_---=-/--'--7_...s,y'---4.$(__,,,_a=~~--- Rc p" r Led 11y --------\-~-...L---=::.. ________ Lab Number ______ 4 ___ /""')__,7L--!o.Q.._.9.._·.__7.._. _____ _ DHS 3]91 (Revised 2/84) Solid and Haz ardous Waste GENERAL INFORMATION A sample analyse s r equest 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) conta iner (i.e., ground or surface water from landfills) a sample label mus t be a ffixed t o one of the containers. The collector must then write the s i te 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 AN ! -'i~ ~.,.-r· • -· _ _,.. . . .-..;_~~-#--:-•._~.:. ~,;J~~! Site Numb e r - 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. Environmental - 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, r es i ns, 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. t x tractables are only performed on a solid or semi-solid. For routine landfill samples, check all parameters in the second and third columns. Organi c Chemistry -Check (v) the de sired 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 s i t (' N 11mhe r __ 9'--'3==----6=-=o=-=-o___,a,c..0=...{_,0.......,.,0--"'CC-• _,cx.__ ________ Fie ld Sample Number OD) lo';).&' f(} N:i mc ol Site fU l-lJJV/) Ft'-<..-Site Location /1-rTo /l.J -...t.---==---=:.:.:..:..:..=,...:.._.:....:::..=------------__ :....:;,_ __________ _ C:o 11 ec ted By {!__.l,f!.-Tc-/2--ID/I ~ {, Date Collected ;~/;,/~ tf Time / :Jo PM --=LL'-_,._-'-----__ .-:......;:;______ > 2 Typl: of Si1mple: Environmental Groundwater t.-/Surface Water Soi.l Other Extractables Concentra te Solid __ Liquid __ Sludge Other tf?c.us A- INORGANIC CHEMISTRY Total Comments W'9T€-a S,91t,tPLf Pnr:1metcr Results mg/l Pa r ame t er Results mg/1 Paramet er Results m~/1 ... Arsenic --J3arium -Cadmium --Chromium -Le::td -Mercury -Selenium -Silver - - - - - - Parameter Endrin Lind<1ne Results rag/1 Methoxychlor ____ _ Arsenic -Barium -Cadmium -Chromium -Lead -Mercury -Selenium -Silver - - - - - - ORGANIC CHEMISTRY Parameter Resu Toxaphene 2,4-D 2,4,5-TP(Silvex) --- - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC Petroleum EDB TOX MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results (MF) Coliform Colonies/lOOmls -Gross Alpha (MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- PCi/1 1);1 tc R('CC j ved_~/,_;:r;l_-~/_,;}__-_:.Jl__,__'/ ..... sc..L-~=-----Da te Reported_~l~~---/~9----.-=.Y:__,_</ _____ _ D ;i l t: Ex trac t ed_t;ii._~-_..,..__._J~----=-~-'-'-/...aJ3,L'J.1)=-___ Da t e Ana 1 y z ed_-L-/...l!::,2_-L../_7L...a--~~~scJtj~:,6.~~~--- __ ___,.,-.,r..-1-+-=-"-===--------Lab Number ________ :]._·r. )_,....,~ __ «" .. _)_? ____ _ R l' p ( q -l l' cl By ·--I OHS 3191 (Revise d 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) conta iner (i.e., ground or surface water from landfills) a sample label must be affixed t o 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/ l = pg/ g = mg/kg ppb = µg/ l = pg/ 1000g = /lg/kg DEFINITIONS/INSTRUCTIONS AN 1 198 -----, .. , ~ ..• i ' :-. .'.-;_►..fr,.~-~~·~ ... '=;.~:--~~ Si te Number -A twelve-digit s ite/location identifier, assigned only by the district field representative. Fie ld Sample Number -A six-digit sample identifier which is pre-printed on the sample label. Name of Site -Name of landf ill, 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. Environmental -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, 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. t x 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 lis tea, 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 N11mber 1(3 -000 l!/0 I ooo ~ Field Sample Number CJO/0 ·-i:z N; I llll'. () r s i t e tie l✓,4, ,f .J> Fl LL site Loca t ion _ __,;1-:"-'· '-'F'---"--ra_,_rV _______ _ Co llected By {!,,'fL /'c /Z. ID/l ___ ~..:..-6 ____ Date Collected /o?/4/ifTime /()(} M Typ<.: of Sample : Env .ironmental Groundwater ~rface Water Soil Other Extractables Pnr,1meter Results Arsenic -Barium -Cadmium --Chromium -Lead -Mercury -Selenium -Si]ver - - - - - - Concentra te Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total mg/l Par ameter Results mg/1 Arsenic -Barium -Cadmium -Chromium -Lead - -Mercury Selenium -Silver - - - - - - ORGANIC CHEMISTRY Pnrameter Results rag/1 Pa rame ter Resu Endrin Lindane Methoxychlor ____ _ Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Comments k12t9Tr:-,,e C'/t &f:t:.. C Parame t er Re sults - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC Petroleum EDB TOX ml!/ 1 MICROBIOLOGY RADIOCHEMISTRY Parame ter Parameter Results PCi/1 (MF) Coliform Colonies /lOOml s -Gross Alpha (MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- lh tl'. I{(' ce .i ved_~;.-~_-....... /'-;l"'---'j/'---'-t/_13"-'-~--____ Da te Repo rted __ /4_~ __ -;;_/__,_7 __ -_:...er---,-1-I _____ _ Da Lt:: Ext r ac ted_~f:W"'· "1---__.____,__-~J'--Y-.__8'-=-JJ) ____ Da t e An alyzed--~_,'cl"--_-..:..../~7____,-£:"'---"~-"riiJ'""";,=c.._----- l{l' p• n-ll:d f\y --~~---........==c_ _________ Lab Number ______ 4 ........ Q ..... ~ .... ,_,O-...fl ...... l .... :-~) ______ _ DH S 3191 (Revised 2/84) Solid and Haz ardous 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/ 1000g = 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. txtractables 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 S i t (' N 11mbu r __ ql-'3=-..... ---=0"'-=0'--0=-...,0""-"'0~L...;:;O:;.._O.:;;.....;:·o'-"')<-'----------F ield Sample Number O{) /0';)_(;;, N;nnc o r Sit e __ ~_C..--'-8 __ ~_-ll:.../IJ_l)_r._1_1-L __________ S ite Loe at ion A-ET<2>N Co l 1 ec t ed By_=C~/i~l?:~/~€-~/Z-____ IDil __ ;t_:;6 ______ Da te Callee ted 1,;;/11 /.f!/ Time / '1t) ~ /1-1 Ty pt: of Sample : Environmental Gr oundwa t er ...-5 urf ace Water So il Othe r Extractable s P;ir;ime t e r Results Ar senic --Bari um -Ca dmium --Chromium -Lead -Mercury -Sel enium -Silver - - - - - - Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total mg/l Pa r ame t er Re sults mg/1 Arsenic -Ba rium -Ca dmium -Chromium -Lead -Me r cury -Se l enium -Silver - - - - - - ORGANIC CHEMISTRY Parame ter Re sults rag/1 Par amete r Re ~ Endrin Lindane Methoxychlor ____ _ Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Comments t 1.P 4 ~d,_ S:'~~?c Parame t e r Resul t s - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC meter B's Petroleum EDB TOX IDS!/] MICROBIOLOGY RADIOCHEMISTRY Parame ter Pa rameter Results PCi/1 (MF) Coli f orm Colonies /lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- 1);1 t c R(' c e .i v ed _ __,_/c-"-~_-_,_/-',}_'----=--<ff~,,_,,,8=--"~-'=----_Da t e Reported j.) 7 7 -f ,,_f-c--------- D,t LL' Ex trac t ed__.,/'-'el'--,~--~__,,-~'----'--~-L/~=g_'.Af)_· __ Da t e Ana lyz ed----#-/.~~--L-1-L-2~-~r-r--!..V=.8-=>,IP~--- Rc P" 1-Ll.'.d By ___ _,.s:::;;oWt:;--t=-~~==--________ La b Numb er _______ 4_. __ l_)_7_0_~_,_,J_. ____ _ OHS 3191 (Revised 2/84) Solid and Haza rdous Wa ste 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) conta iner (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/ 1000g = /Jg/kg DEFINITIONS/INSTRUCTIONS Si te Number - A twelve-digit site/location identifier, assigned only by the district field representative. Fie 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. 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 ~he 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 S i t(• Numb e r q1~ o oo o~iOO(J) X Field Sample Number Oo /{o ~-~ N:nn e o r S ite ft,J lA/J/)£1 t.-L-Site Location _ _,._.tff-L-F_,@~-=-/U=<--------- Co 1 k c ted By C! llf2-T€fL: IDll __ -.:;__h,.:::;__ _____ Date Collected /3, /t, lw Time ![30 M t • t Ty pt: of S.1mple : Environm ental Gr oundwa t er u./Surf ace Wa ter Soil Other Extra ctables Concentra te Solid __ Liquid __ Sludge Other Comments ttru } L~' t u 8T~R 91!/f.-lPLk INORGANIC CHEMISTRY Total P,1 r :1 me ter Re sults mg/l Par ame t er Results mg/1 Par amete r Results ms.!/ 1 Ar senic Arsenic Chloride ---Ba r i um Ba rium Conductivity ---Cad mium Cadmium Copper ----Chromium Chromium Fluoride ---Le;:id Lead Iron ---Mercury Me r cury -Mang anese --Selenium Se lenium Nitrate ---Silve r Silver pH ---Sulfat es ----TDS ---Zinc ----TOC --- --- ORGANIC CHEMISTRY Parameter Endrin Li nd;1ne Re sults rag/1 Pa r ame t er Resu eter •__..:_-+--~.::..:.;_.;:_:;_.;:_:;_ __ __._,""--'-''-"'--"'-'---""'-"'-~-'+-__;;_....:::...::-=;;~;_;:;_:c___ __ ___. ........ ~~i'---'"+'r<~ Toxaphene 's 2, 4-D Pe trole um Me thoxychlor ____ _ 2,4,5-TP (Silvex) EDB ---TOX MICROBIOLOGY RADIOCHEMISTRY Pa r ame ter Pa rameter Results PCi /1 (MF) Coliform Colonies/lOOmls Gross Alpha --(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- lhtc Rvc-e jved_~/,_:_~_,_· ---L/=J._--'--.--"'/------'-/_·_,&~',().~ ____ Da t e Reported /.J,-19 -JA/-~------ D.t t e Lx tr ac t ed---/4~+-+'e...-==~¥-."/..-· __._.tf:~'f~AL:C_J/J=--__ Da t e Ana ly zed___,_/_'.2_• _-_1_7..--.q--f___.</,...__~=W},..__· ___ _ Rl'p<>rlccl By _ / l Lab Num ber 4 ·· 7CJ9':.r ·-------''c+b,,JL-_,._________ ----------------- OH S 3191 (R e vised 2/84) Solid and Hazardous Wast e GENERAL INFORMATION . A sample analyses r equest form (DHS 3191) must be completed for each type o f 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 = ,ug/lOOOg = pg/kg DEFINITIONS/INSTRUCTIONS ~CEili, IAlt 'l l!'" Si te Number - A twelve-digit site/location identifier, assigned only by the district field representative. Fie 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- 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. txtractables 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 93 -00D04/oao,k N:1me or Site /Je,_,,,p L-1JA)i)r1LL- C:ol lccted By C,fb/2T-€:/7- Field Sample Number Q6 /~ sA-f Site Location _ __._t1:~,•~r__:;T◄_O~tv _______ _ ID#_--=U=-_____ Da te Collec ted/j1rp y:· Time/1 ..:ro l'JM Typ<..: of Sample: Environment.:il Groundwater ~urface Water Soil Other Extractables P n r ;une t er Results J\rsenic ---Barium -Cadmium --Chromium -Le ad -Mercury -Selenium -Silver - - - - - - Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total mg/l Paramete r Results mg/1 Arsenic -Barium -Cadmium -Chromium -Lead - -Mercury Selenium -Silver - - - - - - ORGANIC CHEMISTRY Parameter Results rag/1 Parameter Res Endrin Lindane Methoxychlor ----- Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Comments wA r€-~ S'l?h/'t:-t Parameter - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC I troleum EDB TOX Results mg/] MICROBIOLOGY RADIOCHEMISTRY Parameter (MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls - - - OHS 3]91 (Revised 2/84) Solid and Hazardous Waste Parameter Results PCi/1 Gross Alpha -Gross Beta - - - 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) conta iner (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/ 1000g = /Jg/kg DEFINITIONS/INSTRUCTIONS Si t e Number - A twelve-digit s ite/location identifier, assigned only by the district field representative. Fi eld 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- 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. 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 ~~heck(~) the desired parameter to be analyzed. If not listed, ehter 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 Si tP Number '/'3 -(]QfJ ao / oo o k Field Sample Number <i!Jo /t:. ~3 N:1111 e or Site /h,f] ltl>dJ /J F t l--L-Site Location_-'-d.L...IL.ftr;....._-'-N ________ _ Col 1 ccted By {!,A,f<-TE./<_ IDll _ ____,;;1c..;.6=-____ Date Collected /,;J./4 /£' )(' Time /(t:Jo If~ • I T y pl! of S;imple: Environmental Groundwater ~urface Water Soil Other Extractables Comments Concentrate Solid __ Liquid __ Sludge Other h T 0~ B ,l,z/A-t~R Sr!,r'-4/JL-[z INORGANIC CHEMISTRY Total P.1r;1meter Results mg/1 Paramet e r Results mg/1 Parameter Results mg/] Arsenic --Barium -Cadmium --Chromium -Lead -Mercury -Selenium -Si]ver - - - - - - Parameter Resul t s 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) --- - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC Petroleum EDB TOX MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results (MF) Coliform Colonies/lOOmls Gross Alpha --(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- PCi/1 D:1 t c Rc ce j ved __ /L-'~C....,.....-_,...,/~~------=-~_._f~/3r-=-l!)=--____ Da te Rep or ted __ /_.L __ -_/~7_-_f __ </~------ D.1 t L' J·:x tr ac ted~/'-~=.<-.¥/..-L--__ -__..r'---l-'-/---'13.'-=-----.4)..:....._ ___ Da t e Ana lyz ed_~J_,;)._-....,1 .... z-:--:--.--c-c,-Y-'-'l.-'--"13"'-'',lf)--=----- RL' P" r Ll!d By ------'<:'F-H~"'--'""'~---------Lab Number ______ 4_~ }_7_0_9_· ..c:1=-. _____ _ OHS 3191 (Revised 2/84) Solid and Hazardous Waste GENERAL INFORMATION A sample analyses r e quest form (DHS 3191) must be completed for each t ype of eva luation reque sted (e.g., inorganic, organic, microbiology, radio- ch emistry). For sampling conditions which require more than one (1) conta iner (i.e., ground or surface water from landfills) a sample label mu s t be a ffixed t o 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 Numb e r - A twelve-digit site/location identifier, assigned only by the district field representative. Fie 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 Ti.me Collected -Self-explanatory. Env ironme ntal - A sample of a naturally occurring substance such as ground- wa ter, surface water or soils which may be contaminated. Concentra te - A sample of a waste, including but not limited to, sludges, r e sins, 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, ente'r 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 Nt1mber C/3-00QCPQ>/O CIO,d-: Field Sample Number OGJ/{o ;;)._.;\_ N;1111e of Site fl,-{3 l fl,✓,O E1 1.,t--Site Location_--"A~f__,Tc:...,O..,.;A/'-"'---------- C:o 11 ected By (!.A/2-T<E/f'.. IDtl ___ ;;/_6 _____ Date Collected //). /I I /?t/Tirne lttJ&A#-1 Type of Sample : Environmental Groundwater ~urface Water Soil Other Extractables Concentrate Solid __ Liquid __ Sludge Other Comments u T /.2.S:-,,,,. ~,4T£:'.,<.. :S,4~PLb INORGANIC CHEMISTRY Total P;i r;1metcr Results mg/1 Paramet e r Results mg/1 Parameter Results mg/] Arsenic Arsenic Chloride ---13arium Barium Conductivity ---Cadmium Cadmium Copper ----Chromium Chromium Fluoride ---Lead Lead Iron ---Mer cury Mercury -Manganese --Selenium Selenium Nitrate ---Silver Silver pH ---Sulfates ---TDS ---Zinc ---TOC --- --- ORGANIC Parame ter Endrin Lindane Results rag/1 Parameter Re~ ·--+---------~=""-"-....,._..'--"-~---...C...,,.'--'-'-'.C.::....:;...;;..;c ___ ~~ ............................ _,..~ - - - - Toxaphene 2,4-D Methoxychlor 2 ,4,5-TP(Silvex) Pe troleum EDB --------TOX MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter (MF) Coliform Colonies/lOOmls Gross Alpha (MPN) Coliform Colonies/lOOmls Gross Beta - - - Results PCi/1 1);1 rt: R l· (' ('. j V ed_-+-/IL;J"----_,/'--',.C.J_-_,,,_R_1/.,__.l!.t3'"'-=£J::.._ ___ Da t e Reported /.).. -/ 7 -r ...... </'-.-------- [);i l c J-:x trac t ed__,·/.1117'-t-""?T">lit---_..-_._tfL-..,L'-/_-___,,,i£]=i.J)=-__ Da t e Anal y z ed _ _,_/_~_-~/_J,____-=-/_½----=/i.'--I.IJ=----- 4 { __ ,' """41 090 Rep",-Led l)y ---'-:"'-'1--F-..-..-:::::;.--------Lab Numb e r ______ ·---'--=--=-------- DHS 3191 (Revised 2/84) Solid and Ha zardous Waste GENERAL INFORMATION A s ample analyses r e quest 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 t o 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/ 1000g = JJglkg DEFINITI ONS/INSTRUCTIONS Site Number - A twelve-di git 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 ironmenta l - A sample of a naturally occurring substance such as ground- wa ter, surface water or soils which may be contaminated. Concentra te - A sample of a waste, including but not limited to, sludges, r es ins, 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. Or ganic Chemistry -Check (v) the desired parameter to be analyzed. If not listed, enter •the name in the space provided. Mi crobiology 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 SitC' N11mbc.•r _ __,9'--3_ ...... __ o_._o_o_Q) __ o-'/'--c>;:;.._o_c_.._,k....__ ______ Field Sample Number C,0 /6 :Z O N:11ne of Site Jt?e..L!? L~fl,/1/.0/'/-£<:.-· Site Location _ ___,A_,_.ET@-+..=,A/~------- Co 11 ecte<l By C,/;;e,c,e.. IDll _ _,~~( _____ Date Collected JJ.. /It /?f Time /0 t./~"1/t1 ~ l TypL: of Sample: Environmental Groundwater Surface Water Soil ~er Extractables Concentrate Solid __ Liquid __ Sludge Other Comments .IN Ft-u 6 ,&1 r INORGANIC CHEMISTRY Total P;ir:1metcr Results mg/l Parame t e r Results mg/1 Parameter J\rsenic Arsenic Chloride ----13arium Barium Conductivity ---Cadmium Cadmium Copper ----Chromium Chromium Fluoride ---Lead Lead Iron ---Mercury Mercury -Manganese --Selenium Selenium Nitrate ---Si]ver Silver pH ---Sulfates ---TDS ---Zinc ---TOC --- --- ORGANIC CHEMISTRY Parameter Results rag/1 Parameter Rec;ultc; ma / Pa¼meter Endrin Toxaphene V PCB's ---Lindane 2,4-D Petroleum ---2,4,5-TP(Silvex) Methoxychlor EDB ---TOX --- --- MICROBIOLOGY RADIOCHEMISTRY Results ms.r/ 1 Ro c ,.l t-c mn /1 <D , J o/'h T Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls - - - OHS 3191 (Revised 2/84) Solid and Hazardous Waste Gross Alpha -Gross Beta - - - Da t e Reported /,;}. -/ 'j -f '/ Dat e An alyzed /o{ -/ 7-f </ ,84) "'Lab Number 4H7088 GENERAL INFORMATION A s ample analyses request form (DHS 3191) must be completed for each type o f 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 AN 7 Si te Numbe r - A twelve-digit site/location identifier, assigned only b y 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. 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. t x 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. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611 Si tc· Number ~ _ O 0 0 &QI/ O Oe> x Field Sample Number (!)0 IG;;)... / N;1mc of Site f)M L,.IJt<J/.JrtL"-Site Location rJ rroAI Co ll cc ted By C~/L--r<c/7-IDll _ _;;;):.....:(; _____ Date Collected J-2 /!'//fY Time /.::L&o f.11,, Typ<..: of Sample: Environmental Groundwater Surface Water Soil 0'her Extra ctables P.:1r;1meter Results Arsenic --Barium -Cadmi um --Chroll)ium -Lead -Mercury -Selenium -Si]ver - - - -- - - Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total mg/1 Paramet e r Results mg/1 Arsenic -Barium -Cadmium -Chromium -Lead -Mercury -Se lenium -Silver - - - - - - ORGANIC CHEMISTRY Comments Parameter Results mg/] Chloride - -Conductivity -Copper Fluoride -Iron - -Manganese Nitrate - -pH Sulfates -TDS -Zinc -TOC - - Parameter Endrin Lindane Results rag/1 Parameter Requ •--=-4--=-=--=--=-=-=--=-=-------!..>~..l.!...!a.;......'----l.!.i,,;..<.---'1-----=..:::=,;t.=~=.:-----.J.U::...:u.L.W....::>.,----L¥,,.4-f Toxaphene - - - - Methoxychlor ----- 2,4-D 2,4,5-TP(Silvex) --- Petroleum EDB TOX MICROB IOLOGY RADIOCHEMISTRY Parameter Parameter (MF) Coliform Colonies/lOOmls Gross Alpha (MPN) Coliform Colonies/lOOmls Gross Beta - - - Results PCi/1 lh t Li Rt·, c .i ved_~h~~--~/~J_-~P~Y~6--.cLJ ____ Da te Re ported /;J--/7 ...... Jl_--'-<-j ______ _ Dal c Lx tract ed--L./-'-~-=----=-/___,'7'---------'-f"---L...<f---'-l3~;{) ____ D ate Ana 1 y z ed _ _,/'---~--..i.../_7___,-£"'----+'-/-----".8""-'l./)'-=------ R l' jl<l ,-Led By ___ -'<pcH--+--,,,-~1-~-------La b Number _____ 4 ___ -:}_~_,_Q_8_·9 _______ _ OHS 3J91 (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/ 1000g = /Jg/kg DEFINITIONS/INSTRUCTIONS Site Number - A twelve-digit site/location identifier, assigned only by the district field representative. Fie 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. 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. t x 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. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611 Site Number 9-?c?Duuo / Oe>o .J~ Field Sample Number Oo /ro 9: Name of Site f:t7._L[ l -1/N.fJ F(t..<..-Site Location /l-rTo,1/ /1J . ( Collected By/(l,;?l'.J«.1)/ /2?fll<'TT-·t' IDtf ·J~ Date Collected JI /4--/4«/Time //DO fj·/1'.1 7 ---------, , · Type of Sample: Environmental Groundwater Surface Water Soil Other Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Extractables Parameter Results mg 1 Arsenic Barium Cadmium Chromium Lead Mercur --=,..,,,,...,...------s s· Parameter Endrin Lindane Results rag/1 Methoxychlor ____ _ Total Parameter Results mg/1 Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver ORGANIC CHEMISTRY Parameter ReR Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Comments Parameter Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc Petroleum EDB TOX Results m /1 MICROBIOLOGY RADIOCHEMISTRY Parameter (MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls - - - Date Received / / /4 / flt/ .81) ,· Date Ex tract~(g/.f't/gJ() _ Reported By /?. /lf CA-k._ DHS 3191 (Revised 2/84) Solid and Hazardous ~aste Parameter Results PCi/1 Gross Alpha Gross Beta - - - Date Reported_!._._,tf'--'/.......,'J._,/'-'i ....... · f,___· ______ _ Date Analyzed~/i~'/ t'-"1_,7'-4/'-'v,L_,Ly_· ...,,A..e:'.4?:,s__ ____ _ Lab Number _____ 1"'",l)..,,,..,f;~2"---.--47'-,;~l,__ ____ _ 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 = 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. txtractables 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 93 00 O c, o I o o o 4 Field Sample Number Qa /f;-2.).f Name of Site ft_.;J (. A ,.v P F, t l-Site Location #F 70 ,.,..) ,. .N• ( ; Collected By /r,~/-.lv1~s/f1 /rl!l':IE~ ID{! :} (; Date Collected /( /5-/g -/ Time JO /S-,,,_r,,1 / ---=---=-------~ I Type of Sample: Environmental Groundwater Surface Water Soil C,/Llther Extractables Concentrate Solid __ Liquid __ Sludge Other Comments /JJ ,-'-IA E,JT INORGANIC CHEMISTRY Total Parameter Results mg 1 Parame ter Results mg/1 Parameter Results m /1 Arsenic Barium Cadmium Chromium Lead Parameter Endrin Lindane Results rag/1 Methoxychlor ____ _ Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver ORGANIC CHEMISTRY Parameter Res Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Chloride Conductivity Copper Fluoride Iron _ Manganese Nitrate _ pH Sulfates TDS Petroleum EDB TOX MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results (MF) Coliform Colonies/lOOrnls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- Da te Received /I /0 /p( .,6,& Date Reported J1/;7/f( (3,JJ Date Extracted d& /,(t/ .ilJ Date Analyzed 13/1 i/t'/ c3£) Reported By~_,_, -"'-'ZJ'--"-• ...:./V---=='-"o...--(________=-----,--Lab Number 1 £>622,1 DHS 3191 (Revised 2/84) Solid and Hazardous Waste PCi/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 Si te Number - A twelve-digit site/location identifier, assigned only by the district field representative. Fi eld 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 Chemi$try -Check (v) the desired parameter to be analyzed. If not listed, el'!ter 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 93-,AjqtJd/tU6X Field Sample Number C)o/.:!Vi Name of Site /e.,G l!",N.t:hU-Site Location 11{ToJJ, ;U. C. • > Collected By M£.TG/( IDll_""'"A'-'b::;...._ ____ Date Collected /o d_tJ_h'1.I Time // J01'f.f ~rr Type of Sample: Comments Environmental Groundwater Surface Water Soil Concentrate Solid Liquid Sludge Other Uf L IA f,, K Other Extractables Parameter Results mg 1 Arsenic Barium Cadmium Chromium Lead 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 Toxaphene 2,4-D 2 ,4 ,5-TP(Silvex) --- Parameter Chloride _ Conductivity Copper Fluoride Iron Manganese Nitrate _ pH Sulfates v-(Ds Zinc TOC Parameter PCB's Petroleum EDB TOX RADIOCHEMISTRY Results m /1 Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha --(MPN) Coliform Colonies/lOOmls Gross Beta -- --~ -- Date Received ______________ Date Reported __ /_o_-_/_S __ -_g_,_( ______ _ Date Extracted ______________ Date Analyzed ______________ _ Reported By Lab Number ____ .C_4_3_3_6_, _QC-'--"-T'---1 J'--""-8__,_4 __ 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 t/3--oa::>oo/O<::>o X Field Sample Number (J'Jo/:Jf/J' Name of Site /J~J L-AtJ/> f-LL..'-Site Location f}£"[l'JtJ ~ Al~ ( , Callee ted By (!.i .etc/< IDll_---"'/2.:..{,;;;.._ ___ Da te Callee ted P,h ~ /?';/ Time IJ 05_,'},tf Type of Sample: Comments Environmental Groundwater Surface Water Soil Concentrate Solid __ Liquid __ Sludge Other UJ1:1&£NC Other Extractables Parameter Results mg 1 Arsenic Barium Cadmium Chromium Lead Me Se Parameter Endrin Lindane Results ra /1 Methoxychlor ____ _ MICROBIOLOGY INORGANIC CHEMISTRY Total Parameter Results mg/1 Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver ORGANIC CHEMISTRY Parameter Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Parameter Chloride Conductivity Copper Fluoride Iron Manganese Nitrate _ pH ~!fates Zinc TOC Parameter PCB's Petroleum EDB TOX RADIOCHEMISTRY Results m /1 737 Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta ----• -- Date Received ______________ Date Reported / O~ /S-~ff Date Extracted ______________ Date Analyzed ______________ _ Reported By ____________ Lab Number ___ __:,4c...:..4:ui3"'-'3L.5=---'QC::.=..l.:__I _f _8_4 __ _ OHS 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. WILMINGTQN ST., RALEIGH 27611 Site Number Cf l · O~(!){!)O I 0{!)0 X Field Sample Number 00 It/,, Name of Site fC.B Lf Site Location :tlf 7: YO telcS /l()~lUl;iv-,. Collected By #(fUZNQSJCJ Type of Sample: IDll __ --=..{..o,:j:...._ ____ Date Collected 'f In/ sy Time ___ _ Environmental Groundwater Surface Water Soil 7other Extractables Parameter Resul t s Arsenic -Barium -Cadmium -Chromium -Lead - -Mercury Selenium -.,. . -Silvf;r ·-'·, -,· \ -. ' - -; \ I - ,-.; -) .;:, \. ,· ~ .. Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total mg/l Par ame t er Results mg/1 Arsenic -Barium -Cadmium -Chromium -Lead - -Mercury Selenium -Silver - - - - - - ORGANIC CHEMISTRY Parameter Results rag/1 Parameter Resu Endrin Lindane Methoxychlor ----- 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 Results mg/l MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- Date Received __ -4-1--+-iz=-=-~--=---<---_::.... ___ Date Reported ___ 1-+-/4 /~·q½/~f.._ _ _,_ _______ _ r1 :;..,..,_..;'-l=J=..J_.::.:_.;;i~--.:....L...JL.-==:....:..~-Date Analyzed __ ~9~/-J~gY/~·g"--,)':,__ ______ _ ab Number __ :::;i4,:,.Q""' . .A.,5.a:i0.._1 --1·Jµ3._,L._ ______ _ Da te 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 eval~ation 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 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. 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. I norganic 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. t , 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 'l3 ·~oOe;ol t90<P )( Field Sample Number_.....:D.....:o:....L/...s'/_'r,.__,_? ____ _ Name of Site_ ...... P_C.--=&--=C...:::..f.___ ______________ Site Location Tlfi'. WD,Z#c:'S £f~Uc'Nr Collected By KAtJJt>.S/C1 ID/I IS' Date Collected er&J-i. '( Time /D;/o Type of Sample: Environmental Groundwater Surface Water Soil ./ Other Extractables Parameter Results Arsenic -Barium -Cadmium -Chromium -Lead - -Mercury Selenium -Silver -, -.. - - I '·, -,,.; (~~ 'L.~'1· -\ ,_:.•~·~ ; - t~-~. ' ·•;( .,'">/• - ' ·~\) 1."1, ~ (-l-;· ~ '('-~y ;:.1··. ~~-~:~ Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total mg/1 Parameter Results mg/1 Arsenic -Barium -Cadmium -Chromium -Lead -Mercury -Selenium -Silver - - - - - - ORGANIC CHEMISTRY Paramet er Results rag/1 Parameter Re~u Endrin Lindane Methoxychlor ____ _ 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 mg/l MICROBIOLOGY RADIOCHEMISTRY Parameter (MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls - - - DHS 3191 (Revised 2/84) Solid and Hazardous Waste Parameter Results PCi/1 Gross Alpha Gross Beta - - - 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. txtractables 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 t,t,ooo • Site Number __ 'f"""3_ .. "'""~~.:;.___,(.___,c,""'-"o_C!>.:o:a-.X...,_ _________ Field Sample Number_".;:;,cc2""'--'(__.1._.c._o=-------- Name of Site_,..p....:C..:......::.l? __ (-...f _____________ Site Location X.11.l.. VJ¢{Yd E.t:f. Collected By Mf?A,JOSI(/ IDl/ __ ...;:,_r-_____ Date Collected ;1,Jgv Time 16?0 Type of Sample: Environmental Groundwater Surface Water Soil ...&L_Other Extractables Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total Parameter Results mg 1 Parameter Results mg/1 Arsenic Barium Cadmium Chromium Lead --~~;::-__,;_;'--- Parameter Results mg/1 Endrin -Lindane - -Methoxychlor -- ,_ Arsenic Barium ' Cadmium Chromium Lead . Mercury ,-. Selenium ,._ Silver ORGANIC CHEMISTRY Parameter Re~11l re: 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 -./ "1\J!i:Ru21 rr Results m•/1 0,-,c,.,, t-c, -~ /1 I 1..L/ 0 MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha --(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- Date Received _______________ Date Reported __ __,£9_-~/'--'-?_-~9c...,,:1/. _______ _ Date Extracted Date Analyzed Reported By -----------Lab Number_======4:2::1 o:2::s:E:P::12:-8_-4_-_-_-_-_ 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. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611 Site Number 11.,. 4S'ff~, 900 0 .X. Field Sample Number t?O 111 9' Name of S ite__,p~c-'cr""--" • ...:::l:;..~;;_--_____________ Si te Location Tltl WOil/:.$ 1,4!{,t.Jf wT Collected By ,:;,~lvOSet IDll _ ___;;l...:S;;... ______ Date Collected trLJc If'( Time O'f20 Type of Sample: Environmental Groundwater Surface Water Soil 20ther 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 Parameter Endrin Lindane Results rag/1 Methoxychlor ____ _ Arsenic -Barium -Cadmium -Chromium -Lead - -Mercury Selenium -Silver - ORGANIC CHEMISTRY Parameter Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Chloride _ Conductivity _ Copper Fluoride Iron _ Manganese Nitrate --pH Sulfates -TDS Zinc -roe Parameter PCB's Petroleum EDB _)'OX _.,/ ~lfl4)1Tt MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha --(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- Date Received _______________ Da te Reported __ ~_,_L_-_,/'---"-3_-_g~;{'--·--------- Da te Extracted ______________ Date Analyzed _____ --=--=--=----c---------- ~._,.." IO I SEP I?_ ·s-; __ ~,.·, Reported Dy Lab Number ~ '-_____________ ___;_;:........:_..;.__ OHS 3191 (Revised 2/84) Solid and Hazardous Waste I 1 ' N. C. DEPARTMENT OF HUMAN RESOURCES DIVISION OF HEALTH SERVICES STATE LABORATORY OF PUBLIC HEALTH P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH Site Number_----'-P,_'3_-_ll_o_0_0_0_/_0_o_a_.:....Y _________ Field Sample Nu Name of Site f (!,_t ~d.(} I/ Site Location~....(./...L3iii~~-;,,1-~~---- Collected By __ (~~--=.:~'-+== ____ ID# __ ~_~....:_ _____ Date Collected-=:.....L-....:....::......L..=....t.._ Type of Sample: Environmental Groundwater Surf ace Water Soil Other Extractables Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total Comments Parameter Results mg/1 Pa rameter Results mg/1 Parameter Results mg/1 Arsenic Arsenic Chloride ---Barium Barium Conductivity ---Cadmium Cadmium Copper ---Chromium Chromium Fluoride ---Lead Lead Iron --- -Mercury -Mercury -Manganese Selenium Selenium Nitrate ---Silver Silver pH ---Sulfates ---TDS ---Zinc ---TOC --- --- ORGANIC CHEMISTRY Parameter Results rag/1 Parameter Res Endrin Lindane Toxaphene 2,4-D Methoxychlor ____ _ 2,4,5-TP(Silvex) __ _ Petroleum EDB MICROBIOLOGY Parameter (MF) Colif orm Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls - - - Da te Received Ji -J~ ,-g f Date Extrac~te ~2.0_-K '/_':!!.c Reported By_ 't5f-;/t--e ..:__ -" DHS 3191 (Revised 2/84) Solid and Hazardous ~aste TOX RADIOCHEMISTRY Parameter Results PCi/1 Gross Alpha -Gross Beta - - - Date Reported_J'.::.__-_2_,/_-__:__i'--<-</__,{3=lf)=--------- Date Anal yzed Lab Number ----4-_ ·-.~--1+-s~:-~-•(-} ______ _ ----------------- 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~ 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. t r 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'.J-ooo oo I e>c, o k Field Sample Number ~ o /;;.. 7 / Name of Site ftll ~J.flll Site Location _ _,_,1,_£1.....L..t-~~"'1,__ ______ _ Collected By ~ f-t--IDlf ___ ;:_t:, _____ Date Collected 2 /1.6 /trf/: Time ;?:oo rM Type of Sample: Environmental Groundwater Surface Water Soil Other Extractables Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total Parameter Results mg 1 Parameter Results mR/1 Arsenic Barium Cadmium Chromium Lead Mercury . ...-;(, Seleniu '' ----- . Ea, Silver7~ i:S Parameter Results rag/1 Endrin -Lindane -Methoxychlor - -- Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver ORGANIC CHEMISTRY Parameter Res11l t-<:: mo/· Toxaphene -2,4-D -2,4,5-TP(Silvex) - -- Comments Parameter Chloride Conductivity Copper Fluoride Iron Manganese Nitrate -pH Sulfates t2'TDS Zinc TOC Parameter PCB's -Petroleum -EDB -TOX - - Results m /1 7-20 'Ra""1 +-" mn /1 ~ MICROBIOLOGY RADIOCHEMISTRY Parameter (MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls - - - Date Received Date Extracted Reported By DHS 3191 (Revised 2/84) Solid and Hazardous Waste Parameter Results PCi/1 Gross Alpha -Gross Beta - - - Date Reported 1-l's--gcj Date Analyzed "f . C .. ~JG : 7 84 4 ''' 0 Lab Number I V"'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 2761 Site Number f,3 -{)Cb::x::x:::,/ @OO X Name of Site /?r!J> L~ .f; /I Collected By w,e,,._ /t~a,,w...i,. ID/I ~ Date r -_ ___,,:,o....__ ____ _ Type of Sample: Comments Environmental Groundwater Surface Water Soil Concentrate Solid __ Liquid __ Sludge Other e.f'r/L,(__ed Other Extractables Parameter Arsenic -Barium -Cadmium -Chromium -Lead - --Mercury Selenium -SiJver - - - - - - Parameter Endrin Lindane Results mg/1 Results mg/1 Methoxychlor ____ _ MICROBIOLOGY INORGANIC CHEMISTRY Total Parameter Results mg/1 Par ameter Arsenic -Barium -Cadmium -Chromium -Lead - -Mercury Selenium -Silver - - - - - - ORGANIC CHEMISTRY Parameter Resu t Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Chloride - -Conductivity -Copper Fluoride -Iron -_ Manganese Nitrate - -pH Sulfates V!_DS Zinc - - - TOC Petroleum EDB TOX RADIOCHEMISTRY Results mg/l Parameter Parameter Results PCi/1 - - - - Dat e Dc1te (MF) Coliform Colonies/lOOmls (MPN) Coliform Colonies/lOOmls DHS 3191 (Revised 2/84) Solid and Hazardous Waste Gross Alpha Gross Beta - - - . ' .. ,, 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. Da te and Time Collected -Self-explanatory. Environmental - A sample of a naturally occurring substance such as ground- wate~, 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. txtractables 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 27 Site Number_j2~'.3-:e.__~00-=-D_o___:;o'---'-/~O~O:......c.o---=-k,.._ _________ Field Sample Nu - Name of Site _ _.__f_G~l,~~l~<_-~_~_d_f.~,~~I_/ __________ Site Location:____L.!_!_~=3',~~~ffFJr;,,,;,,~-- {!tu·f~, /4()..-..11 ev: IDl! __ __;:;d-;..._;:,b,,___ ____ Date Collected Collected lly Type of Sample: I -"'-"-'-=-+--'-I-+-=+- Environmental Groundwater Surface Water Soil Other Extractables Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total Comments /~~'/IA,,etd- Parameter Results mg/ 1 Parameter Results mg/1 Pa ramete r Results mg/l Arsenic -Bar:i,um -Cadmium -Chromium -Lead - -Mercury Selenium -Silver - - - - - - Parameter Results rag/1 Endrin Lindane Methoxychlor ____ _ Arsenic -Barium -Cadmium -Chromium -Lead -Mercury -Selenium -Silver - - - - - - ORGANIC CHEMISTRY Parameter Resu t Toxaphene 2,4-D 2,4,S~TP(Silvex) __ _ Chloride -_ Conductivity -Copper Fluoride -Iron - -Manganese Nitrate - -pH Sulfa tes _cI'DS - - - Zinc TOC Petroleum EDB TOX MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results (MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/10-0mls Gross Beta -- -- -- Dnt e Received Date PCi/1 Number 4 -~ ;'-. -----l!i!-11----=:.....;__...=:..c...:,...:......._,LL._ _____ _ l 27 19 DHS 3191 (Revised 2/84) Solid and Hazardous Waste M~t 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/ 1000g = )lg/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. Environmental -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. cxtractables 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 pr~or to sampling for either of these. f 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 Cf3 -0(1t,O(>t c, r',<.) .x Name of Site fC fs l f Collected By fA,zt.et? Field Sample Number_....:()=O=-..!...J/ JOll....!,SI~(.,=----- S ite Location j ~ / 1vr(.<Jt,4,IJ ID# ________ Da te Collec te-d--,-=-z~'---'-/~i'-'f--'--T-im-e--=_~~~(~o~-/..:::0~~ Type of Sample: Environmental Groundwater Surface Water Soil ✓Other Concentrate Solid __ Liquid __ Sludge Other Comments · ~~¥pt- Extractables Parameter Results mg l Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver Parameter Results rag/1 Endrin -Lindane -Methoxychlcir - - - INORGANIC CHEMISTRY Total Parameter Results mg/1 Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver ORGANIC CHEMISTRY Parameter Result-c rna /· Toxaphene -2,4-D -2,4,5-TP(Silvex) - - - Parameter Chloride Conductivity Copper Fluoride Iron Manganese Nitrate ,_ pH Sulfates TDS Zinc TOC 7 TCJ~01p1T, Parameter ✓PCB's Petroleum -EDB -TOX - - Results mr/1 o~,.,,,, re m~ /1 <o,1;>;3b MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results PCi/1 (MF) Coliform Colonies/l00mls Gross Alpha -(MPN) Coliform Colonies/l00mls Gross Beta -- -- -- Date Received _____ ~',°=--~7'----~--'-J-?~g __ -__ Date Reported ___ __,~""'---'L_'--tj'----_-_f_c/---~- Da te Ex tr a c ted ___ ...... fr...:,,o:__--1.l__,~=----"'~'-7z_+ ____ Da te Analyzed ____ l,~-_-,_L/_,:3=--~-'/!C__,Ly'_""'/J~W""'-- Repor ted By ________________ Lab Number ______ -1_~ _· J_•-_1--'•--=1 .:....;""=-' ___ • ___ _ DRS 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 q1 •t9c::>Ot>o I ooo X Field Sample Number e:>O 13 B "7 Name of s i te_..i.P_l=-'-B=--L_f-_· ______________ site Loe a tion 1: h/ 6 f/!<.u e,.,,,, Callee ted By_Cc....;4--'-"'f:..L'l_.1;,,:;._;·,:...:.l _____ ID/I ________ Da te Callee ted 6/4 Ivy Time '0 y t:, Type of Sample: Environmental Groundwater Surface Water Soil ~ther Extractables Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total Parameter Re sults mg 1 Parameter Results mg/1 Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver Parameter Results rag/1 Endrin -Lindane -Methoxychlcir - - - Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver ORGANIC CHEMISTRY Parameter Re,;ul t-~ rn n /~ Toxaphene -2,4-D -2,4,5-TP(Silvex) - - - Parameter Results m1 /l Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC c/ 't<.J RB I O fl):: Parameter ✓PCB's -Petroleum -EDB -TOX - - Roc,,lt-c -~/1 <t>,I IJf>b r MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- Date Received ____ ___,y-:;__~_7_-_J>._.,,_='-· ,.,. ____ Date Reported __ ftz_._."---· _-__,/'---'</'---___.:::.J}_Y _____ _ Da te Ex tr ac ted ___ --1.U;,n_-___,__/---=;)'---_-..,.r!j_'--I-----Da te Analyzed _ __,_{R"'-. --~/-'J-c-,~-~Y~Y_...._,4-=-'-~-=----- Repor ted By Lab Number 4 ~ ;314J ---------------------------------- 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 = JJg/kg DEFINITIONS/INSTRUCTIONS Si te Number - A twelve-digit site/location identifier, assigned only by the district field representative. Fie 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. 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, 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. txtractables 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 Cf 3 -OO{)Oe> I ()00 X Field Sample Number t!>Of 2S-O -----="-=c.....:......;....;c __ ..;.._ __ _ Name of Site_A_cg__,,,;...____;::L::::....;_f. _______________ Site LocationTtMT"1l~t: woks f6-LUl!AJi Collected By KA1'lnJDU/ IDII IS-Date Collected s/:J/9.'"1 Time <D.Jo Type of Sample: Environmental Groundwater Surface Water Soil ✓Other Extractables Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total Parameter Re sults mg 1 Parameter Results mg/1 Arsenic Barium Cadmium Chromium Lead Parameter Results mg/1 Endrin -Lindane -Methoxychlor - - - Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver ORGANIC CHEMISTRY Parameter Re~;ul re: ma / Toxaphene -2,4-D -2,4,5-TP(Silvex) - - - Comments Parameter Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC --;/_ TU 11 Bl t> Ilk: Para.meter ~PCB's Petroleum -EDB -TOX - - Results mr/1 D,-.~,,1 t-n , . <D.•L ~6. , MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- Date Received ___ ~:5:,__:-'V_--'F~Yi------Date Reported _ _,,,~:Z:_-_:;_;2_,__/_-_?;:.........,f'-----,-______ _ Date Ex tr ac ted _ _.,..5:::...._-..,_/ ..... ,,).:::...._-~f..,__:/_-'--_____ Da te Analyzed_---=,5'-------"-/--'_5=--~----'£~/-_,,_(3."""'J.!l=..::... ___ _ Rep ort ed Ily _______________ La b Number ______ •1_0_;~-'• >-="""5...,5..,.· ,__ ____ _ 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). Fqr 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 = µg/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 Numb e r_q_;....;:;i;..__-_O_t:>_,O=--..;;.O_O;;;_..__{ _;O:__;Oc.........=a;;..._)(-1--_______ F ield Sample Number () () / z 'i Cf Name of Site pc [? l F Site Location T~IAT,..,f;vr '-JOQJ INJ-:LUEJVJ" Collected By_,,,,t',.:;..,q....,e-.:.,J~()=S=/t.,_t ____ ID/1 __ __,__/...::.S--____ Date Collected s-lJ{g'-( Time C ,,10 Type of Sample: Environmental Groundwater Surface Water Soil / Other Extractables Concentrate Solid _._Liquid __ Sludge Other INORGANIC CHEMISTRY Total Comments Parameter Results mg 1 Parameter Re sults mg/1 Parameter Results m1 /l •----------------J'"'-'-----1 Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver Parameter Results m.g/1 Endrin -Lindane -Methoxychlcir - - - MICROBIOLOGY Arsenic Chloride Barium Conductivity Cadmium Copper Chromium Fluoride Lead Iron _,Mercury Manganese Se lenium Nitra t e Silver pH ORGANIC CHEMISTRY Sulfate s TDS Zinc TOC L I'-'l?Bli:>\1t Parameter Resul re: mo /· Parameter Toxaphene _0>CB's -2,4-D Petrole um --2,4,5-TP(Silvex) EDB --TOX -- -- RADIOCHEMISTRY D nc,111 re ~ D,tapp.b Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls - - - Da t e Received S"-f/--t'f Date Extrac ted 5'-LJ.. -8: ti_ Reported By DHS 3191 (Revised 2/84) Solid and Hazardous Waste Gross Alpha -Gross Beta - - - Dat e Reported 5 -dl/-Jlf Date Analyzed S -1!>--~ y 60 Lab Numbe r 1 0~.154 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.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611 Site Numbe r_-'(J'--':f"----O_o--=o;_oc........;;;o;_c....;:{L-.:0___,;;;0;__:0~X...._ _______ F ield Sample Number () 0 I 2 'i Cf c.s( Name of Site pc_ {? l F Site Location I'?IATryf;yr ""°itlJ INBUE.vr Co 11 e c ted B y_=~.._,'}.._.2"-"/\J..;::;..,,c.O""'S=j!"'-' ----IDll __ --=-l ~S" ____ Da te Collected d J/ g l( Time D 'f..JO Type of Sample: Environmental Groundwater Surface Water Soil 7 Other Extractables Concentrate Solid _._Liquid __ Sludge Other INORGANIC CHEMISTRY Total Parameter Results mg 1 Parameter Results mg/1 Arsenic Barium Cadmium Chromium Lead Mercu Selen· Silve Parameter Results mg/1 Endrin -Lindane -Methoxychlor - - - Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver ORGANIC CHEMISTRY Parameter Res11l t-c: mo ll -Toxaphene 2,4-D -2,4,5-TP(Silvex) - - - Comments Parameter Results m1/l Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC -;z_ IURBI o nt Parameter p,,.,..,, .. .,. --/1 _lC'1'CB's Petroleum -EDB -TOX - - MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha . --(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- Da te Received S" · ((.,-f 'f Date Reported -------------------------------Date Extracted ______________ Date Analyzed _______________ _ Reported Ily ________________ Lab Number ______ •1_~--~~i;_-=.>~·1~J£-..... • 1L-___ ~~--- 35464 tll~ZZi~ 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 cs( Site Number 'J3 -O()ooe> I tPOO X Field Sample Number t!>OI 2S°O --=~_;_ ___ .;,._ __ _ Name of Site_P_(E-"" __ L~f--_" ______________ Site LocationttMJ"1l'-''t wOkl f,=AoJ:Nr Collected By_K)....,A"""1""'"l_N_D"'"'~-"-+-I-----IDll _ __,__I =S-_____ Date Collected shftA'-1 Time CO.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 Parameter Results rag/1 Endrin -Lindane -Methoxychlor --- Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver ORGANIC CHEMISTRY Parameter Res11l tc:: mo/· Toxaphene -2,4-D -2,4,5-TP(Silvex) - - - Comments Parameter Results m1 /l Chloride Conductivity Copper Fluoride Iron Manganese Nitrate -pH Sulfates TDS Zinc TOC 7 TUilBtotTt Parameter _LPCB's Petroleum -EDB -TOX - - Roc1>1 t-c mn /1 MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha # --(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- Date Received ____ ~f:~---''+--~f➔f _______ Date Reported _______________ _ Date Extracted ______________ Date Analyzed _______________ _ •11 ,•;, 1 t _·c -Reported Ily ________________ Lab Number _______ ._._/_!..--=·~~L..._.,~t'------- DHS 3191 (Revised 2/84) Solid and Hazardous Waste 3546J MlY22 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 '13 -tJt9t:>oo I C9C?O X Field Sample Number t:>00 S S-6 Name of Site f L 8 LF Site Location __ ~tt..L.,L-e~t~o~,v..:;__ ______ _ Collected By _ _,__Ki-'--A.....:....::.f_"'-..,.o'-S=~'-I.____ __ IDll __ ___:;.l...::g=--____ Da te Collected J? /'l '( Time I ooo Type of Sample: Environmental Groundwater Surface Water Soil X. Other Extractables Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total Parameter Results mg 1 Parameter Results mg/1 Arsenic Barium Cadmium Chromium Lead Mercury Seienium Silver Arsenic Barium Cadmium Chromium Lead Mercury ·selenium Silver ORGANIC CHEMISTRY Comments /Nt-LUl;.tv7" Parameter Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC _m Results m /1 Parameter Endrin Lindane Results rag/~l~-P~a=r~a=m=e~t=e~r __ ~R£e~s.!,!..b..1..>2-W~+_:_.::;.z..=~=---__.,,~u.J...L..1.....:i......u.'trli-'-, Toxaphene - - - - Methoxychlor ____ _ 2,4-D 2,4,5-TP(Silvex) --- Petroleum EDB TOX ~-Pl:= MICROBIOLOGY RADIOCHEMISTRY Parameter Parameter Results (MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta - - - PCi/1 ~ ./i J1 /J~ // Date Received __ ~i./:'-1-/~3~/~·g~<l~·---------Date Reported_-+-l...,._"-"~-1'(-·_/_UC£-.G. __ ~ __ -=:,_-1 l Date Ex tr ac ted_""""if,-·+/-=6'-J/ ..... •8'...,,<-j..,_· ________ Date Analyzed___, __ ___..,_.+r=-./r-O.,,.i/..,.c8/,_,~.,..,.._------- Rep or ted By Lab Number 7 1 97 ---------------------------------- DRS 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 = µg/lOOOg = pg/kg DEFINITIONS/INSTRUCTIONS Site Number -A twelve-digit s i te/location identifier, assignfq only ' I "" ':; by the district field representative. Field Sample Number - A six-digit sample identifier which is pre-print~~ on the sample label. i: . Name of Site -Name of landfill, facility, etc. .. ,, .. . ' . Site Location -Address, street number, state road, etc. Collected By -Name and ID of sample col lector. 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 wa stes. 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 tH~ name in the space provided. Microbiology and Radiochemistry -The Raleigh office should be consulted prior to sampling for either of these. Cs; 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 'f 3 • t)OOt!>O t coo)(, Field Sample Number---'C'-0---"-0_,S".....,._S'_"l ____ _ Name of Site l'C..(l <...f Site Location _ __,_A.,;;...<-t ..... ro.=...;...N _______ _ Collected By f<AIZ@.JIC/ IDll _ _..:,.1-l,i~ ___ _..:Date Collected ,,tf ,i/ I 'I Time {106 Type of Sample: Environmental Groundwater Surface Water Soil AOther Extractables Concentrate Solid __ Liquid __ Sludge Other INORGANIC CHEMISTRY Total Parameter Results mg 1 Par ameter Results mg/1 Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver Lindane Methoxychlor ____ _ Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver ORGANIC CHEMISTRY Parameter Re Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Comments E ff LLJ,;,,Jr Parameter Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC Petroleum EDB TOX ~ Results m /1 MICROBIOLOGY RADIOCHEMISTRY Parameter (MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls - - - Date Received f,13_1~ r 1 Date Extracted '=t. L61.8'/.../ I I Reported By DRS 3191 (Revised 2/84) Solid and Hazardous Waste Parameter Results PCi/1 Gross Alpha Gross Beta - - - Date Reported Date Analyzed Lab Number 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 condi tions 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.O. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611 Site Number 1 5--t;uooo/ Jo<,• x; Name of Site {vb L..---f Collected By f-,(i. IZ1f I\. Field Sample Number2..; ~~::.....::.O.=-Sll."2~·:!!!t!.~~=--- Site Loca t ion_-,L-/!1---.1.c'---· ,_[t..i;.(')"-'<'-'1}...__ ____ _ ID/1 __ 1-_I ____ Date Collected ~/'1 /J,7't/1 Time /0 .·/_r)Jfz Type of Sample: Comments Environmental Groundwater Surface Water Soil Concentrate Solid __ Liquid __ Sludge Other fc, 8 ll41vDfll l- >~ther Extractables Parameter Arsenic -Barium -Cadmium -Chromium -Lead -Mercury -Selenium -Silver - - - - - - Parameter Endrin Lindane Results mg/1 Results rag/1 Methoxychlor ____ _ MICROB IOLOGY INORGANIC CHEMISTRY Total Parameter Results mg/1 Par ameter Arsenic -Barium -Cadmium -Chromium -Lead - -Mercury Selenium -Silver - - - - - - ORGANIC CHEMISTRY Parameter Res Toxaphene 2,4-D 2,4,5-TP(Silvex) --- Chloride - -Conductivity Copper -Fluoride -Iron - -Manganese Nitrate - -pH Sulfates -TDS -Zinc -TOC - - arameter PCB's Petroleum EDB TOX RADIOCHEMISTRY Results mg/l Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls -(MPN) Coliform Colonies/lOOmls - - - Date Received Date Reported By DHS 3191 (Revised 2/84) Solid and Hazardous ~aste Gross Alpha Gross Beta - - - Date Reported J -;;;._ -8i..J /fL-6 Date Analyzed 3./9£1 ab Number 4 · 1-'1 ' -~~ ... t, GENERAL INFORMATION ,\t i ~ l '!!,',' •. -· ... " ?,: A· s~~p'r'e analyses request form (DHS 3191) must be completed for each type ~f· 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. txtractables 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 STAT E LABORATORY OF PUBLIC HEALTH P. 0. BOX 28047 -306 N. WILMINGTON ST., RALEIGH 27611 07 :?-: { ,'-\ V c --,7 Site Number_-'-2.::...__--___,.\(..t.)J.X.:..-::::/:..;'C..::::.'"'.:...:,G::::/:.....>...::___L-'_--_o_0_· __ .,..,...l,_\ ______ Field Sample Number Oc.U _'>-") Name of Site fc .. -13 ~F Site Location lr-tc ON . Collected By C'.Ji f_---pE,(l> Type of Sample: IDll __ /'1.;_l-..... { ____ Date Collected f,/7 £,0 Time ;u ,(l~-tit? Comments Environmental Groundwater Surface Water Soil Concentrate Solid __ Liquid __ Sludge Other /'GB LJl/,vO~Jt.L ;p bther Extractables Parameter Arsenic -Barium -Cadmium -Chromium -Lead - -Mercury Selenium -Silver - - - - - - Parameter Endrin Lindane Results mg71 Results rag/1 Methoxychlor ____ _ MICROBIOLOGY INORGANIC CHEMISTRY Total Parameter Results mg/1 Parameter Arsenic -Barium -Cadmium -Chromium -Lead - -Mercury Selenium -Silver - - - - - - ORGANIC CHEMISTRY Parameter Toxaphene 2,4-D 2,4,5-TP(Silvex) __ _ - - - - - - - - - - - - - Chloride Conductivity Copper Fluoride Iron Manganese Nitrate pH Sulfates TDS Zinc TOC Petroleum EDB TOX RADIOCHEMISTRY Re sults mg/l Parameter Parameter Results PCi/1 (MF) Coliform Colonies/lOOmls Gross Alpha -(MPN) Coliform Colonies/lOOmls Gross Beta -- -- -- Date Received 3 / 7 / ~ Da te Reported .3/;,z /f'tf /}1.,f, Date Extract~}:(_ ~Date Analyzed __ 8-+/~~r...;./__, 1 ,Y"----'~'----------- Reported By r w, ~------' ab Number ________ __.·1L.:_' ~i~··~· ..... l .::..a;:--'-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 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. D~ARTMENT OF HUMAN RESOURCES DIVISION OF HEALTH SERVlCES STATE LABORATORY OF PUBLIC HEALTH ' P . O. BOX 28047 -306 N. Wilmington St., Raleigh 27611 Site Number 9:5-Po,:,c,cJ d o <5 ,k'. Field Sample Numberov / / 7 ~ Lab ID It ----- Name of "Si t e" .,_8~i'!_l>_..:;.L,_o._. --_d;.._i.£__._i' ._I ._/ __ _ Site Location ;t~f,,~ ,/V.C _....;;_;......:_.L....:.....::....::---,.71...L...--=...~;__--- Callee ted by: C ~f-1-~v ID # __ 1...._{ __ Date Collected ~b(,;tr Time a· : 3o tJ 11., Type of Sample: Environmental Ground Surface -~·oil ..L Other Comments : Extractables Parameter Results Concentrate Solid Liqu.id Sludge Other INORGANIC CHEMISTRY Total Parameter Results Arsenic Barium Cadmium Chromium Lead Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver _ Mercury Selenium Silver Parameter Chloride _ Conductivity Copper Fluor-ide Iron _ Manganese Nitrate pH Sulfates TDS Zinc Results Date Received.....,,.~:..=~'+--Date Reported_:~..!..!::;,c....!..U:;___ Date Analyzed_~.=...:,;~..,.- Reported by_-1-,~---cR,_,_~------Lab Number __ _._Vt7...:;...wt.J;_£~t--_l .... ~'------- DHS 3191 Solid and Hazardous Waste rl5T. ORGANIC CHEMISTRY _____ Parameter ____________ Results Endrin Lindane Methoxychlor Toxaphene 2,4-0 2,4,5-TP(Silvex) . PCB' s Petroleum TOC TOX < Q.j zy i, .---------------------------------------·-·--------·--·-·--Date Received__ J{,.;J_ l,(15::f Date Reported ________ Reported by • /-t.,l..._/;i-:. --~-,--·· 0-6-·'5-5 Date Extracted __ )µ_ _ Date Analyzed_il-/3~'=/::---Lab Number ____ J__ --·--__ _ MICROBIOLOGY Parameter (HF) Coliform Colonies/lOOmls (HPN) Coliform Colonies/lOOmls _____ R_e_s_u_1_ts------=1 Date Received _____ _ Date Analyzed _____ _ Date Reported _____ _ Reported by ____________ _ Lab Number RADIOCHEMISTRY Parameter Results Parameter Results .,__ Gross Alpha -Gross Beta -- --t - - Date Received ------Date Analyzed _____ _ Date Reported _____ _ Reported by _____________ _ Lab Number --------------- N. C. DEPARTMENT OF HUMAN RESOURCES DIVISION OF HEALTH S~RVlCES STATE LABORATORY OF PUBLIC HEALTH P. 0. BOX 28047 -306 N. Wilmington St ., Raleigh 27611 Site Numbet" 13'-· /lOOoc., Io oc..) k" Field Sample Numbet"OC., // 7 S' Lab ID It Name of "Site" S :_ te Loe a ti on __ /l~~~-1-~a~"~-------- Callee ted by: f' ,1 ,e_ r~ &, ID # __ 2 ..... / __ _ Date Collected {/U/41/ Time /I : 00 I Type of Sample: Envit"onmental Ground Surface Soil ~her Comments: Extt"actables Parametet" Results -At"senic -Bari urn --Cadmium --_ Chromium -Lead --_ Met"cury --Selenium -Sil vet" -- --- -- ---- Concentt"ate Solid Liquid Sludge Othet" INORGANIC CHEMISTRY Total Pat"ameter Results Arsenic Barium Cadmium Chromium Lead Mercury Selenium Silver Parameter Results Chloride - -Conductivity -Cappel" Fluoride -It"On -_ Manganese Nitrate - -pH Sulfates -TDS -Zinc - -' ✓ ECB l'Jt 3 ff-l. --- --- DRS 3191 Solid and Hazardous Waste ORGANIC CHEMISTRY ---·----·--·--~-----------------·---------___ h~£lm~ t~-____ . ________ Re ~~_l t ~ ____ _ Endrin Lindane Methoxychlor Toxaphene 2,4-D _j..,4,5-TP(Silvex) ../PCB's Petroleum TOC TOX Parameter Results --------------------···· ------------. --- --------------~------------------------ .---------------------------·------------------------------· -----------------.. Date Recei ved ___ ~fQfL-Date Reported ____________ Reported by ______ _ ~I;;,..:; 1 , , · c Date Extracted ___ J/ 3 ! /8:....':/.._ Date Analyzed __ 2/J/8'=!------Lab Number ___ : __ ~J1,:·-?!5.:-- MICROBIOLOGY Parameter (MF) Coliform Colonies/lOOmls (MPN) Coliform Colonies/lOOmls ____ R_e_s_u_1_t_s ______ =I Date Received _____ _ Date Analyzed ____ _ Date Reported _____ _ Reported by _____________ _ Lab Number RADIOC HEMISTRY Parameter Results Parameter Results -Gross Alpha -Gross Beta -------- Date Received ------Date Analyzed _____ _ Date Reported _____ _ Reported by _____________ _ Lab Number