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CHARLOTIE-MECKLENBURG UTILITY DEPARTMENT
ENVIRONMENTAL LABORATORY SERVICES
• tCl)J -280 OIARLOTIE..
11215 OU.•u:TTI:~ VTn..rn'IM:·~
l~ecidfflburg County, Send REPORT To: Send INVOICETo:
CLIENT: LUESA-Sc6d Waste Seti/ices
FACIUTY: Harrisooig Road Lc:ndiill, Pe,-r;i1 : 50-01 AmberGn}mski JoeHack
ADDRt:-SS: 7819 Hams!)urg P.oad 700 North T l'JC(I Street 700 Nooll T,yon Street
l.ABCOOE: ~SBURG Chaool!e, NC 28202 Chaoo':te, NC 28202
LOCATION DESCRIPTION: GW0-93147
"' ~~ ~ Sample ~laTY!)e ~ Cl1emical .;
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E ., co ., ,, 1 ~ E 0 ~ 'i' g B I 0
Sample ID i= E f i "' ~ s ~ ;::: en ci: l :g c:>
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Instructions: v·-o-~~ Corr~a.'ly;Jlc,;~areas_ ete areasae tor LAB USE Ot.'LY.
For each 1)2:ameler requested, cirde lhe V to verify your reqU!!SI. -'"•· ,,..,nam) -V
Ntl'Iients indL~ NltraeM!lme, TKN, T o!a1 Fhospoours. Almmia
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Far Composnl ~. record Ille au:osam::,er BEGIN end ENO da:eitime.
For Grab saJTill;s. recoro !he ooflecfion lime as !he Sffi1N date'tirre Qniy. Refllql.oisl),d by: (Sqlablre)
Form Revision 08; Effective April 1, 2012
CHAIN OF CUSTODY RECORD
COC#: / (o ()£1,5021> I PAGE 1 Of 1
Sampled By (Print Name): Amber R. Grzymski
Wilness .. "'<i By (Print & St3n Name -If Applicable~
Project Name or Code: HARRISBURG
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CHARLOTIE-MECKLENBURG UTILITY DEPARTMENT
ENVlRONMENT AL LABORATORY SERVICES
------------------~ ------~-, ··------,. -·1 -------· '\" -., ------
NC OENR 05fifi:;afoo t!o. 192; NC OHHS Certiiii;a:ion l\lo. 37417; USE>A ceiefiec1ion No. 01215
l.1ecklenburg County, Send REPORT To: CU:NT: LUESA -Solid Waste Services
FAC!UTY: Harisburg i<oad 1.aia,~D. Pemu1 # 60-01 Amber Grzymsia
AOCRESS: 7819 Hmisoorg Road 700 l'blh Tryoo Street
LAB CODE: HARRIS8URG Chaiotle, NC 28202
LOCATION DESCRlPTION: GW0-93148 .. Sample C.Oledion z ~ Sample Type Sample ;;; ~ ~ Temper.riure Conta:netS
E "' 0 ... '? t I ~ ~ ~ "' ? .s? t .. Sample ID ;::: "' ! ... J § 8 .s? "' E "6 8 g, !'i! C ,:! 8 ~ "' ~ i 8 C:
0 I i 8 i .§ 5 -g .0 "' g E -g 'l5 Q. g "" .. 0 0 .r:::. ~ .!!1 ~ I~ ,:; ~ 0 "' w <.> <.> In z
G-6001-HBW12A ARG lO".t' ~ NA N ii°,9' ~ 2 W,cJ "·· NA X
G-6001-HBW12A Afl..G 11\;.0~ NA
N 1~:i t~i e 1 ( 1.,,.1,,. NA X 8
"' l1Vf< NA e G-6001-!-IB\V12B ARG N l~'d, X 2 ,...,',i_{ir,. NA ~
• \m)
rE.
QoAa.\.OT'l:C•~ ~-'t°"l"II~
Send l>NOICE To:
JoeHack
700 North T ryllll &reel
Charlotte, NC 28202
Chenical
Preservalive
C> I ~ ~ £:;
2 ~ ~ 2 w 8 0 5 8 " "' < ~ "' 52 "' ~ !;:! ~ ,.;; ~ ,f? C, :,:
(~~ (x
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N ~.1 /.~ E 1 (
,,,... ~ ! G-6001-l-1BW12B ARG X § X ~t X jl'<:t';' NA -_, .._
c~·<O NA
N l(D.1-~ 2 .( -) (!, l
G-6001-HBW21 ARG olJb/ln NA X X
G ~~'to NA N ~r r2~0 e 1 (
,_.... ~ ~ ,,..... ) G-6001-HBW21 ARG X 8 X :,,l j X
"' ,, ~J.. NA . ' .,, -~ '-
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N fi'•:> g 2 1 :-.... ..--~ G-6001-HBW22 ARG X ) I X
•..J JI'! ru. NA ... '-I'.::.
}t;!~ ~ NA N ~.3 E ,;-~ ;-'i') G-6001-HBW22 ARG , ... , .. NA 111 X § 11 I ..I "I { I .._
G-6001-HBW17B ARG
, .. ~ NA N tJ.() ! 2 (x i ( ~ f.ln. X X '•l, NA ... -,7·"M NA 2-'b <= ..-" ~ Ir'" D G-6001-l-'13W17B ARG 1,.I u./11, N r7.D X 8 1 ( ~. --( X NA "' i,.._
//'J d,/1', NA ! 2
/' 1, I' ~ ~001-MAINTE ARG ,,. 'ii.Ji>, N 'j..~C X '-lJ '-X I NA ..,. -
/j H)JO NA N,~ X ! i,..--D ~ (~ ~ G-6001-MAINTE ARG , n./11, NA /Jo 0 1 ( X . "' -
Instructions: ,A .~(~7 j_ /
Complete all ye!IOW shaded areas. Slue areas a.-e for LAB OSI: or-a Y. ]/\// ..........
For e""och para,re1ef req~ed. cilt:le lhe ·~ '.o ,~)00[ re~J.leSI. . :~=T '-._>V
Nutriel1ls iooude: Ni~"lrite. TKN, Total Pltosphou!s. Ammonia
nemize Maals Here: Sb, As, 6a, 3e, Cd, Cr, Co. Pb. Ni. Se. Ag, 11. V, Cu, Zn Relinquisoo! by. {Signal!n)
For ~~e sa.,iples, recad the au1Dszmpler 3EG!N a!l3 8'.'D daietiime.
For Grab samples, remn!the~ 6me 2S t1le SEGINda:el"..me(riy. ~by:~)
--
CHAIN OF CUSTODY RECORD
COC#: I ~O(Ji t,03 t I PAGE/ ex=?-
Sampled By (Print Name): Amber R. Grzymski
Wi1nessed By (Print & Sign Name -If Appficable}:
Project Name or C-Ode: HARRISBURG
Analyws CUSTOMER USE au
Field An;t,;si;s
I LABUSEONLY
LABORATORY SAMPLE ID
Co.~
(rnslcm) pH {s.u.)
0-~ ft. I f\FS2.1~it\1 (\(_
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P.e<:!!i';edby:~) D.:!i: Mlit<y Time:
Received by. {Sq.zlure) [);;!a: MfrtayTr:ne: 4-1........._ ..
5c E? e ;.,v,.,.,,: \ tiH.;,.d,f~ "Jt>. '7/;,,_"vf> . l.i....i ...&:
";\" · r h ~ lj \ ' (...v'I. "> +r~t 6f cr:2..0~ io95f'J ,·l-\ 45 Si.:{t,,_. js.}3 G-tG.-it,,
"I'._ 1 11_, -~ ~ ~"'
CHARLOTIE-MECKLENBURG UTILITY DEPARTMENT
ENVIRONMENTAL LABORATORY SERVICES
·--··-.. ··-··•-••T .... -·---··---·· , . ..,.,,_,... ....,.,.. ........ , ....... ,-. ._
NC OE.-.:RCeltfl:a5:>nNo. 19'2; t;COHHS~No.37417;0$ EPA~No.01215
CUENT; ll~rg Coan!y, Send REPORT To:
LUESA • Solid \'tam~
FAClUTY: ~~ l.all!fi.Pemlit:60-01 Amber Qzymski
• «D,
-·--n-:. ~.~ .. ~--I.ITD.ZTY_..._TN•NT
Send INIIOfCE To:
JoeHa:t
-'llORESS: 7819 llalrisln'} ~ 700 ND<1h ,,yen~ 700 N«'.11 T,yon ~
LAB COO~ HAAAl..<:&JRG Chadotte. NC 28202 ~.NC2S202
LOCATION DESCRIPTION: GWO· 93148
j ~ Colledioll E ~ San;,ltTwe Sanple Clle:nic2I An2lr= s ~T~ c«rtainer. ~
i 0
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G-BlM'K . ARG ,1-1,r,.}11 I NA N 2Ss> 1{,C : 2 (--; ) (x Cl~60 NA X
I
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CHAIN OF CUSTODY RECORD
coc~lfoOG(Y>3\I PAGE~)-
~ By (PrintName); AITber R G,zymslci
1'1~ By (Print & Sign Na.T.e. r. ~):
Prt'jec! Mame 0/ Code: HARRISBURG
C\JSrOL!:x USE ONLY
Fie'd ",.,.;.
LA8USEONLY
LABORATORY SAliPI..E ID
~
(m'<::,) pH(s.u..)
A F'ti2-7-o --f ~
J, '
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Instructions::
~,ad~ r..,,.\/. , 1Z:~L7B;f~ °t:.1(,5[ ~ ~r .... L.
Coo,plel!! alyebtsmded -QJe .inoas .a for LAB USE ON!. Y. IL:/!
F« ea:!> paa,r.el!lr ~ cxde ,.. y b ,1'ily yos rec;uest ~ ~-.,~ -~or.~ °*' l,QzyTcc
Ntmn::s ii~ ICra:eimnte. WI, Total PhcsjiK,ws. Ammonia ,:?' .
bemiztl.lt'CalsHerec aM••m~~~~-~n~~~~~ i<t.'nrJn:I t,y: ts,;,:t.zo) µ Receir,d ty: (s:v-e) OalX ,a:,,yr-
Fo,Cctnposi:e~ r!CCCd Ille~ ~.m sro da:!lr.c.
Fer Grab S2m?ies, re:ud :ie ~ eine a; tie 0::-G.'11 ~ o:#f. ~by.~) -..ity:(Sq-.atnl Oalk ~r...,
Form Re'lisiln aa, EJfectr.-e A;,ri ,. 2012
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ENVIRONMENT AL LABORATORY SERVICES
4222 Weslmont Drive, Charlotte, OC 28217 (704 J 336 -2854 er [704) 622 -nao
NC DE.~R Calificaooo No. 19Z NC DHHS Celli5calioo No. 37417; US EPA Cerffic25on No. 01215
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FAClUTY: Ha.'lisburg Road l.andfl, Penni! t; 60-01 ArrwG~
!ADDRESS: 7819 Hamsllu,g Road 700 Nor1h Tryon Street
LABCOOE; HARRISBU~G Challotta, NC 28202
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CHARLOTIE-MECKLENBURG UTILITY DEPARTMENT
ENVIRONMENT AL LABORATORY SERVICES
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Llecklen.burg County, Send REPORTTo: CUENT: LUESA-Solid Waste Servioos
FACILITY: Ha:risburg Roa;j l.andlill, ?emlit # 00-01 Aml>es Grzymslti
ADDRESS: 7619 HairislxJig ~ 700 No.Ol T ryoo S1reet
1.ABCOOE: HARRISBURG Charlot!e, NC 28202
LOCATION DESCRIPTION: GWO • 93149
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Send INVOICE To:
Joe Heck
700 Nortfl Tryon street
CllaJtote, NC 28202
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CHAIN OF CUSTODY RECORD
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\Vllnessed By (Print & Sign Name -If Applicable):
Project Name or Code: HARRISBURG
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