NCD980602163_19851202_Warren County PCB Landfill_SERB C_Field Sampling - Nov 1985-OCR

N·. C. Department of Human Resources
l:>ivision of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number ---49""":;,~t?.......,.~--=ti''--""-/2"""CP-1/.......=..~-'-r)_o-'--5_._ ____ Field Sample Number ---/J~O~L_1~?_2..~--------
Name of Site __ '4'--~----'-"'---"-l~"-~--~-vU_· ________ Site Location __ _,_/1:~f_fo~-h~-----------
~-e-,,. ID# __ ~_C:, ___ Date Collected __ ,_I 1-1/ ..... 1~s_1,_.,/t%""'....,,r;-___ Time ~ 0 D P/lrJ Collected By
Type of Sample:
Environmental
-~ Groundwater ( 1)
Concentrate
__ Solid (5)
__ Surface Water (2) __ Liquid (6)
__ Soil (3) __ Sludge (7)
__ Other (4) __ Other (8)
INORGANIC CHEMISTRY
Extractables
Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic
__ Barium __ Barium
__ Cadmium __ Cadmium
__ Chromium __ Chloride
__ Lead __ Chromium
__ Mercury __ Copper
__ Selenium __ Fluoride
__ Silver __ Iron
--__ Lead
--__ Manganese
--__ Mercury
--__ Nitrate
--__ Selenium
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1
_P&T:GC/MS _EDB
__ Acid:B/N Ext. L.-/pCB's -tCO,J /Ji'Jb '>, _TOX __ Petroleum
--__ Endrin
--__ Lindane
MICROBIOLOGY
Parameter Parameter
__ (MF) Coliform Colonies/l00mls __ Gross Alpha
__ (MPN) Coliform Colonies/l00mls __ Gross Beta
----
----
Reported By -------------------Lab Number
DHS 3191 (Revised 7185)
Solid and Hazardous Waste (Review 7 /87)
Comments
Total
Parameter Results mg/ 1
__ Silver
__ Sulfates
__ Zinc
_Ph
__ Conductivity
_TDS
_TOC
--
--
--
--
--
--
Parameter Results mg/ 1
__ Methoxychlor
__ T oxaphene
_2,4~0
__ 2,4,S~TP (silvex)
--
RADIOCHEMISTRY
Results PCi/1
Purpose: Enforcement and compliance with the N. C. Solid and Hazardous Waste Management Rules.
Preparation A sample analyses request form (OHS 3191) must be completed for each type of evaluation requested (e.g.,
inorganic, organic, microbiology, radiochemistry). For sampling conditions which require more. than one ( 1)
container (i.e., ground or surface water from landfills) a sample label must be affixed to one 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 = µg/g = mg/kg
ppb = µg/1 = µg/1000,g = µg/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 groundwater, 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. Extractables are only performed on a
solid or semi-solid. For routine landfill samples, check all parameters in the second and third columns.
Organic Chemistry -Check ( ✓ ) the desired parameter to be analyzed. If not listed, enter the name in the space
provided.
Microbiology and Radiochemistry -The Raleigh office should be consulte.d prior to sampling for either
of these.
Distribution: 1. Original to State Laboratory of Public Health
Environmental Sciences Branch
P. 0. Box 28047
Raleigh, NC 27611
2. Lab sends copy to Solid and Hazardous Waste Management Branch.
3. Solid and Hazardous Waste Management Branch sends copy to field person.
Disposition: This form may be destroyed in accordance with the Environmental Health, Solid and Hazardous Waste Section of
the Records Disposition Schedule as published by the North Carolina Division of Archives and History.
Additional forms may be ordered from:
Solid and Hazardous Waste Management Branch
Division of Health Services
P. 0. Box 2091
Raleigh, NC 27602-2091
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number ____ 9_:?_o_o_o_o_O......_/_CJ~o_o~x~-----Field Sample Number _~o_o....,J~'f_9_3 ___________ _
Name of Site ___ .,_/>i_G~6--'-~---------j~'+-"'---------Site Location --~,,1-~~~V~o~n~-----------
l½,t-½< ID# ~A~0~--Date Collected ___ l I-+-/,~/ s---+/,-f~f"°'------Time ::2. ,0 fr'vt Collected By
Type of Sample:
Environmental
_ l.__../'Groundwater ( 1)
___ Surface Water (2)
__ Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid ( 6)
__ Sludge (7)
__ Other (8)
r I
Comments
INORGANIC CHEMISTRY
Extractables Total
Parameter Results mg/1 Parameter Results mg/ 1 Parameter Results mg/1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _TOC
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
_P&T:GC/MS _EDB __ Methoxychlor
__ Acid:B/N Ext. ._./PCB's -<iJ,L/Jnh __ · Toxaphene
_TOX __ Petroleum ,--,
_2,4-D
--__ Endrin __ 2,4,5-TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/l00mls __ Gross Alpha
__ (MPN) Coliform Colonies/l00mls __ Gross Beta
----
----
Date Received __________________ _ Date Reported __________________ _
Date Extracted __________________ _ Date Analyzed ......,/4'-"~"--_-..,.;).'-------...... Y. ..... J __ --=8::...;i(}=---------
Reported By Lab Number _____ 5_:_, ~_3_9_. _8_?_· _____ _
OHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
Purpose:
Preparation
. I .
Enforcement and compliance with the N. C. Solid and Hazardous Waste Management Rules.
A sample analyses request form (DHS 3191) must be completed for each type of evaluation requested ( e.g.,
inorganic, organic, microbiology, radiochemistry). For sampling conditions which require more. than one ( 1)
container ( i.e., ground or surface water from landfills) a sample label must be affixed to one 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 = µg/g = mg/kg
ppb = µg/1 = µg/lO00g = µg/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 groundwater, 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. Extractables are only performed on a
solid or semi-solid. For routine landfill samples, check all parameters in the second and third columns.
Organic Chemistry -Check ( ./ ) the desired parameter to be analyzed. If not listed, enter the name in the space
provided.
Microbiology and Radiochemistry -The Raleigh office should be consulted prior to sampling for either
of these.
Distribution: 1. Original to State Laboratory of Public Health
Environmental Sciences Branch
P. 0. Box 28047
Raleigh, NC 27611
2. Lab sends copy to Solid and Hazardous Waste Management Branch.
3. Solid and Hazardous Waste Management Branch sends copy to field person.
Disposition: This form may be destroyed in accordance with the Environmental Health, Solid and Hazardous Waste Section of
the Records Disposition Schedule as published by the North Carolina Division of Archives and History.
Additional forms may be ordered from:
Solid and Hazardous Waste Management Branch
Division of Health Services
P. 0 . Box 2091
Raleigh, NC 27602-2091
N. C. Department of Human Resources
bivision of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 2804 7
306 N. Wilmington Street
Raleigh, 27611
Site Number '13 {)00 0 0 I O D O X Field Sample Number ___ O,'"""'-t:>"""-'-l_,l'.___P_~,...._ _________ _
1 -
Name of Site -~F-t _.v(........,8:;_. __ { __ t7._~-~A4A/4...___;_ ________ Site Location---~~---=~~--='-------------. //
Collected By
Type of Sample:
ud(A____ 10# __ ~_0 __ Date Collected _ ___,lc...:..l--,,,__/_,_1-=.J-+,/_?___;_$" __
Environmental Concentrate Comments
_ V Groundwater ( 1) __ Solid (5) lvf~# ~ A-
__ Surface Water (2) __ Liquid (6)
__ Soil (3) __ Sludge (7)
__ Other (4) __ Other (8)
INORGANIC CHEMISTRY
Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _TOC
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter
_P&T:GC/MS _EDB __ Methoxychlor
__ Acid:B/N Ext. L.---4>CB's <O,/a ah __ T oxaphene , ,
_TOX __ Petroleum _2,4-D
--__ Endrin __ 2,4,5-TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Time
Results mg/ 1
Results mg/ 1
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/l00mls __ Gross Alpha
__ (MPN) Coliform Colonies/l00mls __ Gross Beta
----
----
Date Received __________________ _ Date Reported __________________ _
Date Extracted __________________ _ Date Analyzed --,,.):....::.~-----"~~----"C..f....,,.S'-----"=B-'=JfJ==--· _· ______ _
Reported By ___________________ Lab Number 503988
OHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
Purpose: Enforcement and compliance with the N. C. Solid and Hazardous Waste Management Rules.
Preparation A sample analyses request form (OHS 3191) must be completed for each type of evaluation requested (e.g.,
inorganic, organic, microbiology, radiochemistry). For sampling conditions which require more. than one ( 1)
container (i.e., ground or surface water from landfills) a sample label must be affixed to one 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 =µgi g= mg/kg
ppb = µg/1 = µg/l000g = µg/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 groundwater, 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. Extractables are only performed on a
solid or semi-solid. For routine landfill samples, check all parameters in the second and third columns.
Organic Chemistry -Check ( ✓ ) the desired parameter to be analyzed. If not listed, enter the name in the space
provided.
Microbiology and Radiochemistry -The Raleigh office should be consulted prior to sampling for either
of these.
Distribution: 1. Original to State Laboratory of Public Health
Environmental Sciences Branch
P. 0 . Box 28047
Raleigh, NC 27611
2. Lab sends copy to Solid and Hazardous Waste Management Branch.
3 . Solid and Hazardous Waste Management Branch sends copy to field person.
Disposition: This form may be destroyed in accordance with the Environmental Health, Solid and Hazardous Waste Section of
the Records Disposition Schedule as published by the North Carolina Division of Archives and History.
Additional forms may be ordered from:
Solid and Hazardous Waste Management Branch
Division of Health Services
P. 0 . Box 2091
Raleigh, NC 27602-2091
N. C. Department of Human Resources
·Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number ____ 1..;_3__.CP::;......;;;.O_O___;;;;O_O_,_/_o_o--=o'----'A:'--'----, Field Sample Number __ .a:;,.{)_<J_t_q-'-y---"'-f ________ _
Site Location M"~ Name of Site _ __.f___;;_C...,,/J.._-"'-l~ __ __,.,./n/4:t .... · -'--~---------
_ __._t,...,7d'---"--=----€A_...,------ID# __ 2._,,_b"----Date Collected _......;1'--· t+-1:.,_t -~3 /,___&'_5_-___ _ r , Collected By
Type of Sample:
Environmental Concentrate Comments
~ Groundwater ( 1) __ Solid (5) l,JM,,(,, '#: J__ "8'
__ Surface Water (2) __ Liquid (6)
__ Soil (3) __ Sludge (7)
__ Other (4) __ Other (8)
INORGANIC CHEMISTRY
Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride . _Toe
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter
_P&T:GC/MS ~DB __ Methoxychlor
__ Acid:B/N Ext. CB's <' o , L /J-;;h __ T oxaphene r,
_TOX __ Petroleum _2,4-D
--__ Endrin __ 2,4,5-TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Time
Results mg/ 1
Results mg/ 1
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/ lO0mls __ Gross Alpha
__ (MPN) Coliform Colonies/l00mls __ Gross Beta
----
----
Date Received __________________ _ Date Reported __________________ _
Date Extracted __________________ _ Date Analyzed /,,,.1-,,?--J1J AJt
Reported By Lab Number 3 C:J9S9
OHS 3191 (Revised 7185)
Solid and Hazardous Waste (Review 7 /87)
Purpose:
Preparation
. ,·.
Enforcement and compliance with the N. C. Solid and Hazardous Waste Management Rules.
A sample analyses request form (DHS 3191) must be completed for each type of evaluation requested (e.g.,
inorganic, organic, microbiology, radiochemistry). For sampling conditions which require more. than one (1)
container (i.e., ground or surface water from landfills) a sample label must be affixed to one 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 = µg/g = mg/kg
ppb = µg/1 = µg/1000,g = µg/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 groundwater, 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. Extractables are only performed on a
solid or semi-solid. For routine landfill samples, check all parameters in the second and third columns.
Organic Chemistry -Check ( ✓ ) the desired parameter to be analyzed. If not listed, enter the name in the space
provided.
Microbiology and Radiochemistry -The Raleigh office should be consulte.d prior to sampling for either
of these.
Distribution: 1. Original to State Laboratory of Public Health
Environmental Sciences Branch
P. 0. Box 28047
Raleigh, NC 27611
2. Lab sends copy to Solid and Hazardous Waste Management Branch.
3. Solid and Hazardous Waste Management Branch sends copy to field person.
Disposition: This form may be destroyed in accordance with the Environmental Health, Solid and Hazardous Waste Section of
the Records Disposition Schedule as published by the North Carolina Division of Archives and History.
Additional forms may be ordered from:
Solid and Hazardous Waste Management Branch
Division of Health Services
P. 0. Box 2091
Raleigh, NC 27602-2091
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 2804 7
306 N. Wilmington Street
Raleigh, 27611
Site Number 93 0000 0 /_ o·o o x
Name of Site f e-8 /,,,.._. . .--;.{..~,{
{(o bed's Collected By
Type of Sample:
Environmental
~Groundwater ( 1)
___ Surface Water (2)
__ Soil (3)
__ Other (4)
ID#
Concentrate
__ Solid (5)
__ Liquid ( 6)
__ Sludge (7)
__ Other (8)
Field Sample Number
Site Location
'-1-3 Date Collected
INORGANIC CHEMISTRY
Extractables
Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic
__ Barium __ Barium
__ Cadmium __ Cadmium
__ Chromium __ Chloride
__ Lead __ Chromium
__ Mercury __ Copper
__ Selenium __ Fluoride
__ Silver __ Iron
--__ Lead
--__ Manganese
--__ Mercury
--__ Nitrate
--__ Selenium
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1
_P&T:GC/MS _EDB
__ Acid:B/N Ext. (.../"'PCB's <O,Lap..h ,
_TOX __ Petroleum
--__ Endrin
--__ Lindane
MICROBIOLOGY
Parameter Parameter
__ (MF) Coliform Colonies/lO0mls __ Gross Alpha
__ (MPN) Coliform Colonies/lO0mls __ Gross Beta
----
----
C>O L 2 t" t:,·
A-'--t;;,-._. v
11 '!._13 !... re;-l t Time J 1 f ff"'1
Comments
t-J:::--. 3 /1:
Total
Parameter Results mg/ 1
__ Silver
__ Sulfates
__ Zinc
_Ph
__ Conductivity
_TDS
_TOC
--
--
--
--
--
--
Parameter Results mg/ 1
__ Methoxychlor
__ T oxaphene
_2,4-D
__ 2,4,5-TP (silvex)
--
RADIOCHEMISTRY
Results PCi/ 1
Date Received ___________________ Date Reported ________ _,.,._ ________ _
Date Extracted __________________ Date Analyzed ..,./'-eJ-_--.... 2"'--..,,-"'~--':J.__,...i"",B_~_~· ----------5! tfi990
Reported By -------------------Lab Number
DHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number ___ _.9--"3=--o.::..._;o_o__::.o_c"--'-( .... a"'-· .,,.Qc....,.,-0'---"'-k"-'---Field Sample Number ----'o=-o___./'--'9--'8'"'--·_,_7 ________ _
Name of Site __ ___.f'--"'-v.c....:=t :....__,{----"'-~.....:........:a:.....A----1~~-"'-"'-.,.______ Site Location __ _.A'-'-B-J....:~::..:c....· ----=------------
/.-0 hr? fa+~ ID# _q.,_--:1..._:$ __ Date Collected ----'/._1+-/ ...... J-'---3-+-/_·q.---=~'-----Time / ? 0 /'1l1 Collected By
Type of Sample:
Environmental Concentrate
I I
Comments
J Groundwater ( 1) __ Solid (5) WM ~ s 73
__ Surface Water (2) __ Liquid (6)
__ Soil (3) __ Sludge (7)
__ Other (4) __ Other (8)
INORGANIC CHEMISTRY
Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _TOC
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter
_P&T:GC/MS -~B __ Methoxychlor
__ Acid:B/N Ext. __ PCB's ..co,/ /J1Jh __ Toxaphene
_TOX __ Petroleum
,,
_2,4,D
--__ Endrin __ 2,4,5,TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Results mg/ 1
Results mg/ 1
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/l00mls __ Gross Alpha
__ (MPN) Coliform Colonies/lO0mls __ Gross Beta
----
----
Date Received __________________ _ Date Reported __________________ _
Date Extracted __________________ _ Date Analyzed /c:J.. -d: -£L 8J()·
Reported By --------------Lab Number 503991
OHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
bivision of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number __ 9~J_o_o_o_o_tJ .... /_cJ_o_o_X~-----Field Sample Number _ ___,Q""--=~::;....<_J_...9-=g;__;~;;.._ ________ _
Name of Site __ f_C-_8 __ UJ_~-~~>+·------------Site Location _ __,_,4.......,~<F---------------
Jfo b! ~ ID# _'-........ /:~3 ___ Date Collected __ 11 __ /-1~3~/,.....?~:f ____ Time / I 3 f '1.1! Collected By
Type of Sample:
Environmental
_0,roundwater (1)
Concentrate
__ Solid (5)
__ Surface Water (2) __ Liquid (6)
__ Soil (3) __ Sludge (7)
__ Other (4) __ Other (8)
Comments
INORGANIC CHEMISTRY
Extractables Total
Paran1eter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _Toe
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
_P&T:GC/MS 7PDB __ Methoxychlor
__ Acid:B/N Ext. PCB's <'O, i /J-/1.h __ T oxaphene
_TOX __ Petroleum _2,4-D
--__ Endrin __ 2,4,5-TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/ lOOmls __ Gross Alpha
__ (MPN) Coliform Colonies/lOOmls __ Gross Beta
----
----
Date Received __________________ _ Date Reported __________________ _
Date Extracted __________________ _ Date Analyzed ---,,/~;2_·_-~,;l~--f...,j,_-_~i!:i~&c..--. _____ _
Reported By Lab Number ----S~C'~•3~9_-=9=2~-------
DHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 2804 7
306 N. Wilmington Street
Raleigh, 27611
Site Number ___ -4f.....a3=----ac'""'? .... ?>'-'D"'-=0--=0~/'-"'-0--=0'---o_· X'a..,_ ___ Field Sample Number _ _..O"-"o=-+-,L-'-CJ_rt_:J+-----------
Name of Site --~/3_' ...aact'=~--'-L"""-"-0-~ ......... -J.,,,..,..,1 .... A'-"'4'-'---------Site Location ---'di:.......J..H,_--t:h,"'-""--'~------------
/€0 /o vk ID# l/-5 Date Collected _ _.l'-'-/+-/""--'/3~/'--P._'S'-----Time //3" f/11 Collected By
Type of Sample:
Environmental
~ Groundwater (1)
___ Surface Water (2)
__ Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid ( 6)
__ Sludge (7)
__ Other (8)
r l
Comments
we«, #L/--B
INORGANIC CHEMISTRY
Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _TOC
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
_P&T:GC/MS _EDB
fjl/1-b
__ Methoxychlor
__ Acid:B/N Ext. {..../"'PCB's <o ; __ · T oxaphene
_TOX __ Petroleum r _2,4-D
--__ Endrin __ 2,4,5-TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/l00mls __ Gross Alpha
__ (MPN) Coliform Colonies/lO0mls __ Gross Beta
----
----
Date Received __________________ _ Date Reported __________________ _
Date Extracted __________________ _ Date Analyzed _j_cJ.-_-_,r)_--g-·~c~ .... @-·_i.J)__· _______ _
Reported By ___________________ Lab Number 503993
DHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0. Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number __ .L9..=3__:::o:....o::......::o:....o..:::,_c,~·.4,1_o_o_·.....:o::...,_---'-'k'--____ Field Sample Number _----=:::0::....:0:....L-/...,,.9_9L,._O=-----------
Name of Site PC ,6' ~ J, ., --/ A Site Location A: f 1Jr.-, ~ (I '-IC /tlli..,
Time __ 2_&_f'._f_l_''t-Collected By
Type of Sample:
S: ~ '1-1-J ID# _?._·-'~e......., ___ Date Collected __ ...... /-'-( +/-'l'-=3~/-'·'2=---Z::-"----7 t
Environmental
___ Groundwater ( 1)
t..-/ Surface Water (2)
__ Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid ( 6)
__ Sludge (7)
__ Other (8)
Comments
ur·u 5 tt
INORGANIC CHEMISTRY
Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _TOC
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
__ P& T:GC/MS _EDB __ Methoxychlor
__ Acid:B/N Ext. -i.LPCB's ~o. W,.h __ Toxaphene
_TOX __ Petroleum _2,4-D
--__ Endrin __ 2,4,5-TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/I00mls __ Gross Alpha
__ (MPN) Coliform Colonies/IO0mls __ Gross Beta
----
----
Date Received _________________ _
-. ;') n -w-
Date Extracted ~//,_-...:,.)._o_-8=-=S'--1(-.6?J.:---"'3"'-q_9,_¥._·-_4_oo--'l1'----"-1)P._,__ __
Reported By
Date Reported __________________ _
Date Analyzed .-µleJ.:e...._-_..~=----"1l,,;.;;j:c,..,..,..,.f3..,..&...,· ~~-------0 03994 Lab Number __________________ _
OHS 3191 (Revised 7185)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0. Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number _ ..... 1~:?~0~0_D_O~O---/_O_O_O_~.k _____ Field Sample Number __ C>_0_/_9_9_/ ________ _
Name of Site _p_G_.E_~l~. _(.~-~---~-------~---------Site Location __ A_~,_,_~-~-------------
<:; l~ 4111 ID# _?-_3 ___ Date Collected ___ (.....,( /~l~s~/,__=ff' ..... C ___ Time // '-/ C:-/lHJ Collected By
Type of Sample:
Environmental
___ Groundwater ( 1)
___ Surface Water (2)
__ Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid ( 6)
__ Sludge (7)
__ Other (8)
INORGANIC CHEMISTRY
Extractables
Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic
__ Barium __ Barium
__ Cadmium __ Cadmium
__ Chromium __ Chloride
__ Lead __ Chromium
__ Mercury __ Copper
__ Selenium __ Fluoride
__ Silver __ Iron
--__ Lead
--__ Manganese
--__ Mercury
--__ Nitrate
--__ Selenium
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1
_P&T:GC/MS _EDB
__ Acid:B/N Ext. ----1.ACB's ~O ,L-f'-f1b.
_TOX __ Petroleum
--__ Endrin
--__ Lindane
MICROBIOLOGY
Parameter Parameter
__ (MF) Coliform Colonies/lOOmls __ Gross Alpha
__ (MPN) Coliform Colonies/lOOmls __ Gross Beta
----
----
I I I
Comments
Total
Parameter Results mg/ 1
__ Silver
__ Sulfates
__ Zinc
_Ph
__ Conductivity
_TDS
_TOC
--
--
--
--
--
--
Parameter Results mg/ 1
__ Methoxychlor
__ Toxaphene
_2,4-D
__ 2,4,5-TP (silvex)
--
RADIOCHEMISTRY
Results PCi/ 1
Date Received ___________________ Date Reported __________________ _
Date Extracted-----------------Date Analyzed _,_/4)~·--.... ,d~--f~r-~s~/4)'----------. 5(~3995 Reported By Lab Number
OHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 2804 7
306 N. Wilmington Street
Raleigh, 27611
Site Number __ _.._9=3--"'0__,0~0=...,,o"'-'Q""+/-'0'--'"'Q'-'O...._d:::__,__ ____ Field Sample Number _....,Cb""""""-'-'/ ..... 9 ...... Cf._2-__________ _
7 -
Name of Site __ ..,,f_c....;g::;..__~_ ......... -+J""""--=A--'----------Site Location __ __,,/}_._· ~i+-:'-"-"-"-' ___________ _
5'~,0,1d ID# --~-'3'"'----Date Collected -~(_l-+/_(_3~,,_/_~_S---___ Time / ,;l c.>c, '? /0 Collected By
Type of Sample:
Environmental
___ Groundwater ( 1)
___i.L__ Surface Water (2)
__ Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid ( 6)
__ Sludge (7)
__ Other (8)
Comments
UTP 5 ft
INORGANIC CHEMISTRY
Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _Toe
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/1
_P&T:GC/MS _EDB __ Methoxychlor
__ Acid:B/N Ext. L/pCB's < tJ ; L f1/J.1J __ Toxaphene
_TOX __ Petroleum r _2,4-D
--__ Endrin __ 2,4,5-TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/l00mls __ Gross Alpha
__ (MPN) Coliform Colonies/lO0mls __ Gross Beta
----
----
Date Received __________________ _ Date Reported __________________ _
Date Extracted __________________ _ Date Analyzed /4}-,;). -£5"' "3.<J!..
Reported By · __________________ _ Lab Number Sn3996
OHS 3191 (Revised 7185)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0. Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number ___ q-'--"--3_· _o_o_c_o_O_/~o_o'-----o"---".x_,__ ___ Field Sample Number -~t:P~~_/_'j_c;,_l _'S _________ _
Name of Site ---'f_C---=6--=-(-~---+~-+-----------Site Location --~A-fP-~--------------
5',~; ID# _2_3 ___ Date Collected ___ t __,1 ,,-6~/ 3---,.(_9~5"___ Time / :2 F "1-r Collected By
Type of Sample:
Environmental
___ Groundwater ( 1)
_L,L'._ Surface Water (2)
__ Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid (6)
__ Sludge (7)
__ Other (8)
INORGANIC CHEMISTRY
Extractables
Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic
__ Barium __ Barium
__ Cadmium __ Cadmium
__ Chromium __ Chloride
__ Lead __ Chromium
__ Mercury __ Copper
__ Selenium __ Fluoride
__ Silver __ Iron
--__ Lead
--__ Manganese
--__ Mercury
--__ Nitrate
--__ Selenium
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1
_P&T:GC/MS --dDB
__ Acid:B/N Ext. _· _PCB's ~O-La1.1b
_TOX __ Petroleum 1,
--__ Endrin
--__ Lindane
MICROBIOLOGY
Parameter Parameter
__ (MF) Coliform Colonies/lOOmls __ Gross Alpha
__ (MPN) Coliform Colonies/lOOmls __ Gross Beta
----
----
Comments
Total
Parameter Results mg/ 1
__ Silver
__ Sulfates
__ Zinc
_Ph
__ Conductivity
_TDS
_TOC
--
--
--
--
--
--
Parameter Results mg/ 1
__ Methoxychlor
__ Toxaphene
_2,4,D
__ 2,4,5,TP (silvex)
--
RADIOCHEMISTRY
Results PCi/ 1
Date Received Date Reported __________________ _
Date Extracted __________________ Date Analyzed __.ft~Q_·_--=-d--_-~f:~) .... -_-/2.1__,__-.. ;0...__ _______ _
Reported By · ___________________ Lab Number 5(?3997
OHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 , Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number __ __,1...,3"--...;;t>;._;:o'-o=-"0"""6=--/1'--0_o_o_x ____ Field Sample Number _ _.Q.._-j,,O"'-l-/_9........_9_f __________ _
Name of Site __ ....L,.e_c.:;;;....,,6::;;.._~l~/M.A.A--'--"-~ft/21~-·__,_ _______ Site Location ---/'-J--Jiplk'f'--'-=-="-------------
S ~; ID# _ ____:;__~.;,..,3.,___ DateCollected _ _,_../l-1-/...._13.....,,,_/f'"--"'-S:----Time 2o5' ftn Collected By
Type of Sample:
Environmental Comments
___ Groundwater ( 1)
/Surface Water (2)
__ Soil (3)
Concentrate
__ Solid (5)
__ Liquid ( 6)
__ Sludge (7)
__ Other (8)
Jf'e, !AS It
__ Other (4)
INORGANIC CHEMISTRY
I Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _TOC
__ Silver __ Iron --
--__ . Lead --
--__ Manganese --
--__ Mercury --
--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter. llesults mg/1
_P&T:GC/MS ~DB __ Methoxychlor
__ Acid:B/N Ext. __ PCB's -< /J, L o. fl. b. __ Toxaphene
_TOX __ Petroleum r• _2,4-D
--__ Endrin __ 2,4,5-TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/IO0mls __ Gross Alpha
__ (MPN) Coliform Colonies/IO0mls __ Gross Beta
----
----
Date Received ___________________ Date Reported __________________ _
Date Extracted _________________ Date Analyzed __,.j,_~_-~,;)~--f_.S--.c.,-,.-,.....x:J.~?lQ..,,... _______ _
"51m9.9M Reported By Lab Number
DHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number C/3 (')0 O O O / C> OQ X Field Sample Number __ &_0_/~?_1~5:~---------
Name of Site --~!'--L~~~IJ~-lp~~-· ~--,.~,....,...--l1~-------Site Location A~
::> ~ ID# _').,_3 ___ Date Collected I l /; "3 p-r;-Collected By
Type of Sample:
Environmental
___ Groundwater ( 1)
\/ Surface Water (2)
__ Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid ( 6)
__ Sludge (7)
__ Other (8)
INORGANIC CHEMISTRY
I Extractables
Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic
__ Barium __ Barium
__ Cadmium __ Cadmium
__ Chromium __ Chloride
__ Lead __ Chromium
__ Mercury __ Copper
__ Selenium __ Fluoride
__ Silver __ Iron
--__ Lead
--__ Manganese
--__ Mercury
--__ Nitrate
--__ Selenium
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1
_P&T:GC/MS _EDB
__ Acid:B/N Ext. V PCB' s <0,Lno.b.
_TOX __ Petroleum r1
--__ Endrin
--__ Lindane
MICROBIOLOGY
Comments
Total
Parameter
__ Silver
__ Sulfates
__ Zinc
_Ph
__ Conductivity
_TDS
_TOC
--
--
--
--
--
--
Parameter,
__ Methoxychlor
__ Toxaphene
_2,4~D
__ 2,4,S~TP (silvex)
--
RADIOCHEMISTRY
Results mg/ 1
llesults mg/ 1
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/lOOmls __ Gross Alpha
__ (MPN) Coliform Colonies/lOOmls __ Gross Beta
----
----
Date Received __________________ Date Reported __________________ _
Date Extracted -----------------Date Analyzed ~/.-~_ .. _,,,~c)-~--~R-..... C.__---J<&.--... · .... o ______ _
Reported By --------------Lab Number $(~3999
OHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Dlvision of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number 9 :! t2 o o a c / o o C )< Field Sample Number __ ...,'2.::.....:0::.__,,/_CJ~Z......,,6"'----------
Name of Site ----=-/>_C.._15' __ ~::;,__:_-=..._fvt,,_,,__.:....·_/l _______ Site Location __ ~_,L-A-1-1~~""'~"'"-..::::...... .. ~-----------
,>VIJ?~ ID# __ :;2__? __ Date Collected --~/w.l~/..._1..::..1~}'--lg':......:....') __ Time ;2 IO f)1.-1 Collected By
Type of Sample:
Environmental
___ Groundwater ( 1)
~Surface Water (2)
__ Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid ( 6)
__ Sludge (7)
__ Other (8)
l I
Comments
,/?a!DS ,A-
INORGANIC CHEMISTRY
I Extractables Total
Parameter Results mg/1 Parameter Results mg/ 1 Parameter Results mg/1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _TOC
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
·--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter. llesults mg/ 1
_P&T:GC/MS _EDB -< tJ, I ,2jl.D. __ Methoxychlor
__ Acid:B/N Ext. f::::::::'.'t>CB's __ Toxaphene
_TOX __ Petroleum ,-_2,4,D
--__ Endrin __ 2,4,5,TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/lO0mls __ Gross Alpha
__ (MPN) Coliform Colonies/lO0mls __ Gross Beta
----
----
Date Received __________________ _ Date Reported __________________ _
Date Extracted __________________ _ Date Analyzed ~P::...__....-_.,di<C..-----iLY ..... J_,_·-_~8..LO..l.£.Q ______ _
Reported By SD4 __ ooo Lab Number _______ ___c:-....::.......:::...._=.. ________ _
OHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number ----+-f -=3'--c:;_o_o--"'c-',o;.+/_e,"--o--"D'--A'.'-·.,__ ___ Field Sample Number -'--,19_o~J_9~a~1_,7,__ _________ _
Name of Site --'-,'9._c_ifl_---'-L_~ _ __,._,.,~"""-"'----+--------Site Location A /TffV')., YI 1 (_ ' ~ f .
Collected By
Type of Sample:
~-f½,J ID# ;!, 3, Date Collected i I / I ;J / '7 Li • 1
Environmental Comments
___ Groundwater ( 1)
_.d_ Surface Water (2)
__ Soil (3)
Concentrate
__ Solid (5)
__ Liquid ( 6)
__ Sludge (7)
__ Other (8)
b~
__ Other (4)
INORGANIC CHEMISTRY
I Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _TOC
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
---__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter.
_P&T:GC/MS _EDB
L O,l .j!/2-l,
__ Methoxychlor
__ Acid:B/N Ext. --1.L'PCB 's __ Toxaphene
_TOX __ Petroleum _2,4~0
--__ Endrin __ 2,4,S~TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Results mg/ 1
~esults mg/1
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/l00mls __ Gross Alpha
__ (MPN) Coliform Colonies/lO0mls __ Gross Beta
----
----
Date Received _________________ _ Date Reported __________________ _
Date Extracted _________________ Date Analyzed /d .,, J.: .,, ,Y J -A)Q
Reported By _______________ Lab Number 504001
OHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
.,
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 2804 7
306 N. Wilmington Street
Raleigh, 27611
Site Number __ ....;,.lf_J_O_O_o_o_o__,_/_o_o_o __ --:X"_,__ ____ Field Sample Number ---=~;..:~=-L..i _.'t'-9""--"g' __________ _
Name of Site ___ j:J_C_6' _ ___,;c,~...c.....--+,j0-1,___-_________ Site Location _ ___,k'--"-'~'F-"-"---"--------------
~ ID# __ )__"?"'----Date Collected __ 1.,_,J /'-"'{=--=3:....../-/-=-7 _:,5_-__ _ Collected By
Type of Sample:
Environmental
___ Groundwater ( 1)
___ Surface Water (2)
,/ Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid ( 6)
__ Sludge (7)
__ Other (8)
, r , Time /I L/~ It&
Comments
INORGANIC CHEMISTRY
I Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _Toe
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
·--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter
_P&T:GC/MS _EDB
__ Acid:B/N Ext. i..../PCB's
_TOX __ Petroleum
--__ Endrin
--__ Lindane
MICROBIOLOGY
Parameter
__ (MF) Coliform Colonies/l00mls
__ (MPN) Coliform Colonies/lO0mls
--
--
Date Received __________________ _
Date Extracted _.,._I ..... J..__✓-.L.tf_.,_.._f_,,a...-_ ___:..as=-<lQ"""-------
Reported By
OHS 3191 (Revised 7185)
Solid and Hazardous Waste (Review 7 /87)
Results mg/ 1 Parameter. llesults mg/ 1
__ Methoxychlor
LO,l/JtJM. r, __ Toxaphene
_2,4~0
__ 2,4,S~TP (silvex)
--
RADIOCHEMISTRY
Parameter Results PCi/ 1
__ Gross Alpha
__ Gross Beta
--
--
Date Reported __________________ _
Date Analyzed ~l.=~----L..✓-✓ ...... r~C_c:..6'.:::..c'.dJ~------~ 504002 Lab Number
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number -----'C/_3_o_0_o_o_o-----=/c......:...O_O--'C>;;.___)< ____ Field Sample Number _ __,,.c>::..,Q...c..Ll_9L......,'}f.....+7 _________ _
Name of Site __ ___;_f'_~----';6=--__ L_~--.,v;;µ__·..;;;....;.A_______ Site Location __ __.fi<....!....p.~c...:::.:~::....·.:....s.... __________ _
ID# _J.__..,3 ___ Date Collected --~' 1+/---'--13_/2~~-=S"-----Time Collected By
Type of Sample:
· Environmental
___ Groundwater (1)
___ Surface Water (2)
t_/ Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid (6)
__ Sludge (7)
__ Other (8)
Comments
INORGANIC CHEMISTRY
I Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _TOC
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
---__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter. Results mg/1
_P&T:GC/MS ~DB __ Methoxychlor
__ Acid:B/N Ext. __ PCB's L"cJi l ~m __ Toxaphene
_TOX __ Petroleum ;-_2,4-D
--__ Endrin __ 2,4,5-TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/l00mls __ Gross Alpha
__ (MPN) Coliform Colonies/lO0mls __ Gross Beta
----
----
Date Received _________________ _ Date Reported __________________ _
Date Extracted _..,_J. .... 'd:'----__,__t/_-__..f'-=J_.,,,_fi......,.d}=· ::,_ _____ _
Reported By
Date Analyzed ~A.=~=----_,-Ly._-_· ·-=--J/_--=J~gF,;:JP,.· ........., ...... -----5 ( g\003 Lab Number __________________ _
DHS 31 91 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number 93 0 ° O 0 C> I O O O X Field Sample Number --b(}i<--"'-O-~_o_· _D--'--0 ________ _
Name of Site _ __._/1_[_,,--=(3"---~--="-'--"--+&;v,=r-"_· __._______ Site Location __ ___,_A-!J-'--1¥~'--"'--'.__ __________ _
Collected By /;ny-p~ ID# -~)-_'3.,,__ __ Date Collected _ ____.l'-'-V,.__,_)/*....;:;3-+-'-0~~5"'----Time /;I t:)t) ;='/J;
Type of Sample:
Environmental
___ Groundwater ( 1)
___ Surface Water (2)
V Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid (6)
__ Sludge (7)
__ Other (8)
Comments
u r 05 A
INORGANIC CHEMISTRY
I Extractables Total
Parameter Results mg/1 Parameter Results mg/ 1 Parameter Results mg/1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _Toe
__ Silver __ Iron --
--__ . Lead --
--__ Manganese --
--__ Mercury --
--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter
_P&T:GC/MS :7nDB
__ Acid:B/N Ext. __ PCB's
_TOX __ Petroleum
--__ Endrin
--__ Lindane
MICROBIOLOGY
Parameter
__ (MF) Coliform Colonies/lOOmls
__ (MPN) Coliform Colonies/lOOmls
--
--
Date Received __________________ _
Date Extracted --/_J_..,,____.(/~-~'~·~J_____,/3 ........... J.P~------
Reported By
DHS 3191 (Revised 7185)
Solid and Hazardous Waste (Review 7 /87)
Results mg/ 1 Parameter. llesults mg/ 1
__ Methoxychlor <.OJ~m __ Toxaphene ,
_2,4,D
__ 2,4,5,TP (silvex)
--
RADIOCHEMISTRY
Parameter Results PCi/ 1
__ Gross Alpha
__ Gross Beta
--
--
Date Reported __________________ _
Date Analyzed j;l .,; ~(f.~,,lQ
Lab Number ___________________ _
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number ___ _.9'--3_· _t)_o_o_O_C>__./'--o_o_o_:::r ...... · ---Field Sample Number -~0.........,<2""--'2=-->,o ...... o.:...,I,__ ________ _
Name of Site ___ ..,a.f>_c, __ ... /1'-----'Lc.....;a~~-=--J..,__,fiA-1~ .... ~--'-'----Site Location ___ 7..,../l:~p~""-=.>"--''------------
,&{vaA.,,{_19-r,v ID# ;)_ ;> Date Collected __ __._!t=-.l~r3=-+-/..:;,.?<,L.S'_'? --Time /-< 0 0 17 11-1 Collected By
Type of Sample:
Environmental
___ Groundwater ( 1)
___ Surface Water (2)
~oil (3)
__ Other (4)
I Extractables
Concentrate
__ Solid (5)
__ Liquid (6)
__ Sludge (7)
__ Other (8)
INORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic
__ Barium __ Barium
__ Cadmium __ Cadmium
__ Chromium __ Chloride
__ Lead __ Chromium
__ Mercury __ Copper
__ Selenium __ Fluoride
__ Silver __ Iron
--__ Lead
--__ Manganese
--__ Mercury
---__ Nitrate
--__ Selenium
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1
_P&T:GC/MS _EDB
I t
Comments
Total
Parameter Results mg/ 1
__ Silver
__ Sulfates
__ Zinc
_Ph
__ Conductivity
_TDS
_TOC
--
--
--
--
--
--
Parameter. llesults mg/ 1
__ Methoxychlor
__ Acid:B/N Ext. _0CB's ~ O , I t)/)11:J __ Toxaphene r _TOX __ Petroleum _2,4-D
--__ Endrin __ 2,4,5-TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/lOOmls __ Gross Alpha
__ (MPN) Coliform Colonies/lOOmls __ Gross Beta
----
----
Date Received __________________ Date Reported ---------=-------------
Date Extracted _/~d-_-_V_-_-_f~-S-:~)l{~dJ~-----Date Analyzed ......,./2c.....:~'-----✓_-_-.,.J"-__ ~:-::--.x!:t,...,,· ~7Aft:,,;-_ ~------, 5f~4005
-------------------Lab Number __________________ _ Reported By
DHS 3191 (Revised 7185)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 2804 7
306 N. Wilmington Street
Raleigh, 27611
Site Number ---~lj~:f_v~·o~~--0(?)--/=0_0_D~K-· ___ Field Sample Number ___ C,0~_2_D_C_::,2 _______ _
Name of Site --~f _c. __ Jt ___ L_~---~_A_,( _______ Site Location ___ -z!t..........,~ ....... -~----------
<' ~ J / l /') 2 I I rf/r" 2 o r-P ldA Collected By
Type of Sample:
./ l \JfUl/Lpt..J ID# -~,,,.,--.2 __ Date Collected -~'~'.,_~1_3~-L~L~--Time :> 1 'yt I l
Environmental Comments
___ Groundwater ( 1)
___ Surface Water (2)
~Soil (3)
Concentrate
__ Solid (5)
__ Liquid (6)
__ Sludge (7)
__ Other (8)
/(L. us A-
__ Other (4)
INORGANIC CHEMISTRY
I Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _Toe
__ Silver __ Iron --
--__ . Lead --
--__ Manganese --
--__ Mercury --
·--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter.
_P&T:GC/MS _EDB __ Methoxychlor
__ Acid:B/N Ext. ¼CB's <(O, I ,1f)fr1 __ Toxaphene
_TOX -~ Petroleum r _2,4,D
--__ Endrin __ 2,4,5,TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Results mg/1
Results mg/ 1
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/lO0mls __ Gross Alpha
__ (MPN) Coliform Colonies/l00mls __ Gross Beta
----
----
Date Received __________________ Date Reported __________________ _
Date Extracted ___ l.=..d--_--_LL..,/_----'f"'--'=j"-./--Ao,6_4)..,,.·.__ ___ Date Analyzed ~/_d_· --~Y_-_r_'----r--",eq. ___ w .... O....__ ____ _
Reported By Lab Number $(\:\006
DHS 3191 (Revised 7/85)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Di\.rision of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 2804 7
306 N. Wilmington Street
Raleigh, 27611
Site Number -,---9~3_CJ_0_6_6_O__,/~o_o_o~X _____ Field Sample Number -~<2~0_.2._o_e,~3~--------
Name of Site --~p_e,_,&~_L_~---z-fAA1-~-------Site Location __ ~A....._~--~-----------
Collected By
Type of Sample:
,;;' '<J(?f_,/4,{~ ID# __ ~~3 __ Date Collected __ ~/t_/.~;~:?_/_9~L~--Time ~a)§' />)0 r i
Environmental
___ Groundwater ( 1)
___ Surface Water (2)
__J Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid ( 6)
__ Sludge (7)
__ Other (8)
Comments
INORGANIC CHEMISTRY
I Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _TOC
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
·--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter. ~esults mg/ 1
_P&T:GC/MS ~B __ Methoxychlor
__ Acid:B/N Ext. . CB's ~·a ,1 ~m __ Toxaphene
_TOX -~ Petroleum r _2,4-D
--__ Endrin __ 2,4,5-TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/lOOmls __ Gross Alpha
__ (MPN) Coliform Colonies/lOOmls __ Gross Beta
----
----
Date Received _________________ _ Date Reported __________________ _
Date Extracted -.#-/-=ol'------___,_(_-__,tf_._-__._C:_A--c.L')j)=--------Date Analyzed +d..:;.62_-.... i:'----f____;;S---.=:4!,:--_w=---------
5TT40'.' 7 Reported By -------------------Lab Number -----------~...;__ _______ _
OHS 3191 (Revised 7185)
Solid and Hazardous Waste (Review 7 /87)
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number ---~9_3~f~~-i')_t7_0_1,_/-/}_~~0~_K~--Field Sample Number _ _____;:;_O....;O:;....::../_t:,_l{--=---'2. ________ _
Name of Site ___ _,f_C,,6.c=.. __ Lc...:;,~_...;:;._-Ft~<-=--,f_______ Site Location __ _./t'--"-R~:;....;:..:::;_......_ ___________ _
>fNz.),)_,eyJ ID# ')... ~ Date Collected ___ ll--+-1/;_/_3_,_/_<Z_5"~--Time ~ I g f /1! Collected By
Type of Sample:
Environmental
___ Groundwater ( 1)
___ Surface Water (2)
~ Soil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid (6)
__ Sludge (7)
__ Other (8)
~ I
Comments
INORGANIC CHEMISTRY
Extractables Total
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic __ Silver
__ Barium __ Barium __ Sulfates
__ Cadmium __ Cadmium __ Zinc
__ Chromium __ Chloride _Ph
__ Lead __ Chromium __ Conductivity
__ Mercury __ Copper _TDS
__ Selenium __ Fluoride _TOC
__ Silver __ Iron --
--__ Lead --
--__ Manganese --
--__ Mercury --
--__ Nitrate --
--__ Selenium --
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1 Parameter Results mg/1
_P&T:GC/MS ~DB __ Methoxychlor
__ Acid:B/N Ext. _,_PCB's .../0,/~l}j __ Toxaphene
_TOX __ Petroleum t _2,4-D
--__ Endrin __ 2,4,5-TP (silvex)
--__ Lindane --
MICROBIOLOGY RADIOCHEMISTRY
Parameter Parameter Results PCi/ 1
__ (MF) Coliform Colonies/lOOmls __ Gross Alpha
__ (MPN) Coliform Colonies/lOOmls __ Gross Beta
----
----
Date Received __________________ Date Reported ------,---------------
Date Extracted _ _,/~J--_--_Y:_-~£"--"J .... ..--_""'A~~ .... ·'--------Date Analyzed __,.A:_bJ_--_~_.,,,--=-f..,..·~j .... -_A~M~-------
Lab Number _____ S_t_~~_-~_0_0_8 ______ _ Reported By
OHS 3191 (Revised 7185)
Solid and Hazardous Waste (Review 7 /87)
• ... · ,_,. .
N. C. Department of Human Resources
Division of Health Services SAMPLE ANALYSES REQUEST
State Laboratory of Public Health
P. 0 . Box 28047
306 N. Wilmington Street
Raleigh, 27611
Site Number ___ _,_t:!/-='.3_0_a.>_o_o ..... J_O_o_0_X ____ Field Sample Number __ O_o_l-1,;/:~--~? ________ _
Name of Site ---~-c,,,,_:E? __ l_.pvvi __ ~_~'+--'"""/4_· -'1_______ Site Location __ _,.~.._~I'---·~-----------
>1,'1J2V'l,{_ drvl ID# _,?-_'3 ___ Date Collected ----'--/1-+/--'1_.J.....,/,___f"~ ___ Time 2 Io r)h Collected By
Type of Sample:
Environmental
___ Groundwater ( 1)
___ Surface Water (2)
--.Lsoil (3)
__ Other (4)
Concentrate
__ Solid (5)
__ Liquid (6)
__ Sludge (7)
__ Other (8)
INORGANIC CHEMISTRY
Extractables
Parameter Results mg/ 1 Parameter Results mg/ 1
__ Arsenic __ Arsenic
__ Barium __ Barium
__ Cadmium __ Cadmium
__ Chromium __ Chloride
__ Lead __ Chromium
__ Mercury __ Copper
__ Selenium __ Fluoride
__ Silver __ Iron
--__ Lead
--__ Manganese
--__ Mercury
--__ Nitrate
--__ Selenium
ORGANIC CHEMISTRY
Parameter Results mg/ 1 Parameter Results mg/ 1
_P&T:GC/MS _EDB
__ Acid:B/N Ext. 0 CB's -<'i'.2 '7 4f)l!'.l
_TOX __ Petroleum r--
--__ Endrin
--__ Lindane
MICROBIOLOGY
Parameter Parameter
__ (MF) Coliform Colonies/lOOmls __ Gross Alpha
__ (MPN) Coliform Colonies/lOOmls __ Gross Beta
----
----
Comments
Total
Parameter Results mg/ 1
__ Silver
__ Sulfates
__ Zinc
_Ph
__ Conductivity
_TDS
_TOC
--
--
--
--
--
--
Parameter Results mg/ 1
__ Methoxychlor
__ Toxaphene
_2,4~0
__ 2,4,S~TP (silvex)
--
RADIOCHEMISTRY
Results PCi/ 1
•
Date Received __________________ Date Reported __________________ _
Date Extracted _j._d_-___._5(_-~i .... ·...:,J ...... ---_ _,,,_,G~.-<fl'->-C------Date Analyzed --;,..,.,...4~b2_---~V_-_r--':r;,=--_,e_~~· =--------
Reported By ----------------Lab Number 5 ~'•1009
OHS 3191 (Revised 7185)
Solid and Hazardous Waste (Review 7 /87)