WQ0011360_GW Monitoring - 03-2021_20210407

GW-59A COMPLIANCE REPORT FORM Permit # w
(Submit one each monitoring period with GW-59 forms.)
360
I
Enter date monitoring results were due. ( NIC\1 Will this monitoring report (GW-59 and GW-59A)
YES
NO
be submitted after the established due date.
2
Was any required information missing on the GW-59 report forms?
YES
NO
IF the answer to question 1 or 2 is "YES" list in the space provided below the well identification number(s) and
explain the problems encountered in obtaining the required information.
3
Are any of the monitor wells in need of repair or maintenance (damaged casing, unlocked or missing cap, missing
identification plate, area overgrown, etc.)? If the answer is "Yes", contact the Regional Office for guidance.
YES
4
Are any monitored constituents equal to or above the established standards?
NO
If the answer to question 4 is "NO" skip to section 8.
If the answer to question 4 is "YES" list the affected wells individually with constituent(s) and concentration(s)
ee ng s das iQ the s provided below: � C l3
a r (A''A((O��
1
(�- ` (�
Ves��, Cs:\ k o cm a co, I I 0 0 INN L ,ecA ca,-6 frn I 0 co
5
For the constituents identified in question 4 above, have standards been exceeded previously for the
same constituent(s) in the same well(s) in the last two years?
NO
If the answer to question 5 is `NO" skip to section 8.
If the answer to question 5 is "YES", list in the space provided below, each well with constituent(s) exceeding
standards, co centration(s) reported, and sample collection date for each occurrence for the last two years).
-w-� cl-- c,-ao S, S Y-tl- !1 s
/
1,
3-4_a1 Sri 3-1a-ao Sjl — (4-lq s,09
,k_ 4— ao S I kk— q —kc\ 5'1 -
Z3
6
Are the monitoring wells listed in section 5 located at or beyond the review boundary?
YES
If the answer is "YES", a groundwater quality problem may be occurring. CONTACT THE REGIONAL
OFFICE IMMEDIATELY FOR GUIDANCE. If the answer is "NO", monitoring wells may be improperly
located; contact the Regional Office.
7
Is the permittee implementing previously approved actions required by the Division involving this
groundwater quality problem?
YES
NO
If the answer to question 7 is "YES", describe those actions in the space provided below.
If the answer to question 7 is "NCB contact the Regional Office within 90 days; an evaluation may be
required to determine the impact a waste dis. al system is havinjat the review and compliance
boundaries surrounding this faci Failwe t• • so may subject tire permittee to a Notice of Violation,
fines, and/or penalties. i
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L7
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8
The person completing this portioJ(GW--59A) of the monitoring report should sign below and submit this
form with GW-59 forms for require wells to the address provided at the top of the current GW-59 form.
I hereby acknowledge that the above information was evaluated and the information submitted in this
report (Compliance Report GW A) is a complete to the best of my (knowledge.
.3 Imam (.30—a
Signature of Pe ittee(or Authorized Agent) Date
9 9 )
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SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
FACILITY INFORMATION Please P 'nt Clearly or Type
Facility Name: �Qc'�-eei Q C‘."k"a\ osC\
Permit Name (if different):
Facility Addr. ss:
�.Zet
• ,..din
(;,trout)
rr;hdef
County 2r•
� � \ 1 !�oCq ul'
Contact Person: C0.\ Vim) ej A(, Telephone#: `0 13 — 3 c3 i
Well Location/Site Name: }- Sl'cte-. `0..y, g- No. of wells to be sampled:
v (from Permit)
PERMIT Number A'� 2.EKplratlon Date
Non -Discharge U UIC
NPDES Other
TYPE OF PERMITTED OPERATION BEING MONITORED
f-6egoon ❑ Remedlatlon: Infiltration Gallery
El Spay Field ❑ Remedlatlon:
SAMPLING INFORMATION
WELL ID NUMBER (from P r It): ci\W Date sample collected: 3 - LE' &l
Well Depth: ft. Well Diameter: '� In.
Depth to Water Level 82548: 6I Q ft. below measuring point Screened Interval: ft. to ft.
Measuring Point Is Q t • ft. above land surface Relative M.P. Elevation: ft.
Volume of water pumped/balled before sampling: 5 gallons
Samples for metals were collected unfiltered: ® YES 0 NO and field acidified: ® YES ❑ NO
LABORATORY INFORMATI N
Date sample analyzed'3) -5), 3- B) 3' t O) Y ��� CO I1-at Laboratory Name: I\II„(.(N,....,
PARAMETERS NOTE: Valdes shotlld reflect dlssoffed and colloidal concentrations.
COD 00335
Collform: MF Fecal 31818
Collform: MF Total 31504
(Note: Use MPN method for highly turbid sampiee)
issolved Solids:Total 70300 9,C)
pH (Lab) 00403
TOC ooeeo
Chloride 00940
Arsenic o1002
Grease and Oils 00552
Phenol 32730
Sulfate 000es
Specific Conductance 000es
Total Ammonia ooeio Q `
(Ammonia Nitrogen; NHS ae N; Ammonia Nitrogen, Total
TKN as N 00825
mg/L
mg/L Nitrite (NO2) as N ooe15
/100mL Nitrate (NO3) as N 00820
/100mL Phosphorus: Total as P mese
Orthophosphate 70507
mg/L Al - Aluminum o1105
units Ba - Barium 01007
mg/L Ca - Calcium 00916
mg/L Cd - Cadmium 01027
ug/L Chromium: Total 01034
mg/L Cu - Copper 01042
ug/L Fe - Iron 01045
mg/L Hg - Mercury 71900
µMhos K - Potassium 00937
mg/L Mg - Magnesium 00927
Mn - Manganese o1o55
NI - Nickel 01067
mg/L
mg/L
mg/L
mg/L
mg/L
ug/L
mg/L
ug/L
ug/L
mg/L
ug/L
ug/L
mg/L
mg/L
ug/L
ug/L
Pb - Lead oio51
Zn - Zinc 01092
Certification No. \kk
ug/L
mg/L
Other (Specify Compounds and Concentration Units):
ORGANICS: (by GC, GC/MS, HPLC)
(Specify test and method #. ATTACH LAB REPORT.)
Lab Report Attached? ❑ Yes (1) ❑ No (0)
VOC 7873 , method #
, method #
, method #
, method #
For Remediation Systems Only (Attach Lab Reports): influent Total VOCs: mg/L Effluent Total VOCs:
❑ Rotary Distributor 0 Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
FIELD ANALYSES:
pH ooaoors% 1 units
Spec. Cond. 00094:
Temp.00010:I °C
µMhos
Odor 00085: QYr\ct_ J
Appearance
0
U
If WELL
WAS
DRY at
time of
sampling,
check
here.
c,pIlliy lft�i;,lp thr. ,nneil I ..innnr.r-on. qu� ) udin 9 ._Yh n mg VOC Rem oval%
hest of myyl in itIa trIn cIt Ic. Iurrim/:rmilyr it dolt, piodrirrd-using approved methods o[an lysis'rGyarPlNjgeljlllec(hnn�lolyfr31- te:possibility ifYPtlin�crit_ oii rnodu iolau)s
"411111116
orized Agent)
Permlttee (or thod d Agent) Name and Title - Please print or type
GW-59 Rev. 06-07-2018
Signature of.Per
(Date)

SUBMIT FORM ON YELLOW PAPER ONLY
Fe - Iron 01045
Sulfate 00945 mg/L Hg - Mercury 71900 ug/L Lab Report Attached? ❑ Yes (1) ❑ No (0)
pacific Conductance 000es µMhos K - Potassium 00937 mg/L VOC 7873 , method #
Total Ammonia maw , 3. mg/L Mg - Magnesium 00927 mg/L method #
(Ammonia Nitrogen; NH, as N; Ammonia Nitrogen, Total) Mn - Manganese 01055 ug/L 9 , method #
Ni - Nickel 01087 ug/L , method #
GROUNDWATER QUALITY MONITORING: ( I �� :l�;ii r jt `,IY :];� ,* IfittUNIr' ,-, :' ''' '
mk,ovf,0 ATaR RIEsOUReas3
COMPLIANCE REPORT FORM �1�{�•?(pMgltlr�t M�4�%0PCIt4Hd'1r
FACILITY INFORMATION Please PantClearly orT pe PERMIT Numbe "bDt( p(ration Date:!d �
31-a0
Facility Name: (71(C-\ee.k Okc\,ko\ `\\-(5n . Non -Discharge UIC
Permit Name (If dI r�eent): NPDES Other
Facility Address: t"v Q [ . ` Q • TYPE OF PERMITTED OPERATION BEING MONITORED
\‘22 (,;lr — County _`(Xct LI-Lagoon
)\ebbe u ray Field ❑Remediatlon:
Contact Person: V.-c
Well Location/Site Name fir)[ C.4iO \CkLET-`(N
SAMPLING INFORMATION ,` ^
WELL ID NUMBER (fro mit):1W d-.., Date sample collected: 3
Well Depth:' ft. Well Diameter:
Depth to Water Level 82548: ‘S—,,C‘ ft. below measuring point Screened Interval:
Measuring Point Is 'a, Z. ft. above land surface Relative M.P. Elevation:
Volume of water pumped/balled before sampling: S gallons
Telephone#C.: 0 — acts —m
No. of wells to be sampled: S
(from Permit)
Samples for metals were collected unfiltered: RYES ❑ NO and field acidified: ® YES ❑ NO
LABORATORY I FORMATION ��,,`
�
Date sample analyzed: — 13- S 3-8)) 3,10 3 / 11—otllaboratory Name: �v\ ('�j0•a `r
PARAMETERS NOTE: Values should reflect fllssolvet� and colloidal concentrations.
COD 00335 mg/L Nitrite (NO2) as N 00815 mg/L Pb - Lead 01051 ug/L
Coliform: MF Fecal 31818 , d CAA /100mL Nitrate (NO3) as N 00820 13 i SS mg/L Zn - Zinc 01092 mg/L
Collform: MF Total 31504 ` /100mL Phosphorus: Total as P 00685 \ v V‘ mg/L
❑ Remediatlon: Infiltration Gallery
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
FIELD ANALYSES: i
pH oo400:Ci3units Temp. 00010:1 iSC
to _ft. Spec. Cond. 00094: µMhos
ft. Odor 00086: (1."(�_i
Appearance
(Note: Uee MPN method for highly turbid (tamples) Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
issolved Solids:Total 70300 36 mg/L Al - Aluminum o11os mg/L
pH (Lab) 00403 units Ba - Barium 01007 ug/L
TOC ooseo mg/L Ca - Calcium 00916 mg/L
Chloride 00940 fl mg/L Cd - Cadmium 01027 ug/L
Arsenic 01002 uglL Chromium: Total 01034 ug/L
Grease and Oils 00552 mg/L Cu - Copper 01042 mg/L ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730 ug/L ug/L (Specify test and method #. ATTACH LAB REPORT.)
sZ:
Certification No. l
TKN as N 00825
mg/L
For Remediatlon Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs:
Perm ttee (or Au}horize
GW-59 F 5V. 06-07-2018
If WELL
WAS
DRY at
time of
sampling,
check
here.
mg/L VOC Removal%
gFrtlfyithslt'doltit 1)t of my I nowle,lge and linlief,'tlte info' inati in subnutteva in this Ioj;rnt is hue accrual,. :inn complete and that then le , b ,L c i.nrn; analylu:�d eh3ta �;aets poi using apj�inviad inzthoels oL�analysls Uy a'°
VyR9eftifiet(labolgl°Iy I a)n•auuafel(Ijat )hele•clle.stgtliflear ponglpes-for .nibipithng false Infaniattion„including the possibility of fines;ancl itnpusonnienl fo' rnovwng,violations.
` �iiltttt�.t�1 ,.
i - �. b • ,� Ir�i7
u orlzed Agent)
•
gent)
Name and Title - Please print .r ype
Mail original
and 1 copy to
Signature of.Per i a
•
3
•
6—
(Date)

GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
FACILITY INFORMATION Please Print ClerfyorType
Facility Name: r\22‘ .C‘AN` \ckk� aY)
SUBMIT FORM ON YELLOViI PAPER ONLY
Mail original
I
and 1 Copy to: ,
Permit Name (If different):
Facility Address:
��c\-e
ivayf
Contact Person:
Well Location/Site Name:
SAMPLING INFORMATION
WELL ID NUMBER (from Permit): W
Well Depth: ft.
Depth to Water Level 8254e: ft. below measuring point
Measuring Point is ft. above land surface
Volume of water pumped/balled before sampling:
Samples for metals were collected unfiltered: ® YES
County WckeLe.cm,
Telephone#:°k\6--Z13 --3`0
% No. of wells to be sampled: S
Date sample collected: 3
Well Diameter: , in
Screened Interval: ft. to
Relative M.P. Elevation: ft.
gallons
❑ NO and fleid acidified: IN YES ❑ NO
PERMIT Numbs
Non -Discharge
NPDES
3EIsiration Date:
UIC
Other
TYPE OF PERMITTED OPERATION BEING MONITORED
11-Eegoon
-spray Field ❑ Remedlatlon:
❑ Remedlatlon: Infiltration Gallery
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
FIELD ANALYSES:
pH o0400:5 I Libnits
ft. Spec. Cond. 00094:
Odor 00085:
Appearance
Temp. °bolo: /A ,3°C
µMhos
If WELL
WAS
DRY at
time of
sampling,
check
here. n
LABORATORY INFORMATION
Date sample anaiyzed:a - tf -1 3-S" 3-$) 3 -10/3 -
PARAMETERS NOTE: Valdes shotld reft6ct dissolved
COD 00335
Conform: MF Fecal 31e16
Dissolved Solids:Total 70300
pH (Lab) 00403
TOC mesa
Chloride (mar)
Arsenic o1002
Grease and Oils 00552
Phenol 32730
Sulfate 00945
Specific Conductance 000ss
Total Ammonia omeio
mg/L
/100mL
Collform: MF Total 31504 /100mL
(Note: Use MPN method for highly turbid samples)
mg/L
units
mg/L
L S mg/L
ug/L
mg/L
ug/L
mg/L
µMhos
I mg/L
(Ammonia Nitrogen; NH,ae N; Ammonia Nitrogen, Total)
TKN as N 00825
mg/L
it -AA Laboratory Name: V� ( Q\Q.N\
and colloidal concentrations.
Nitrite (NO2) as N 00615
Nitrate (NO3) as N 00620
Phosphorus: Total as P °bees
Orthophosphate 70507
Al - Aluminum o1105
Ba - Barium 01007
Ca - Calcium oasis
Cd - Cadmium 01027
Chromium: Total 01034
Cu - Copper 01042
Fe - Iron o1045
Hg - Mercury 71900
K - Potassium 00937
Mg - Magnesium 00927
Mn - Manganese °loss
NI - Nickel 01087
mg/L
0 0 mg/L
a+ arl
Pb - Lead oiosi
Zn - Zinc 01092
Certification No. q
uglL
mg/L
mg/L
mg/L Other (Specify Compounds and Concentration Units):
mg/L
ug/L
mg/L
ug/L
ug/L
mg/L ORGANICS: (by GC, GC/MS, HPLC)
ug/L (Specify test and method #. ATTACH LAB REPORT.)
ug/L Lab Report Attached? ❑ Yes (1) ❑ No (0)
mg/L VOC 7873
mg/L
ug/L
ug!L
, method #
, method #
, method #
, method #
For Remedlatlon Systems Only (Attach Lab Reports):
Influent Total VOCs:
I certify That, to fle beat of my Imotnlodge rtnd betel, Ito Infottn:ition ,Aildnilf. tl r r.:rui1 0s hug ;1 r i.1Io ,1nr1 c ij 1. 1.' nod Ihnl Ili I.11r1i nni " tic iyh1 n rinl:� .t - lunrhu-r rl neuvl :ippioved nu=thuds of analysis by u
I]WR ce)ihed Ioborttoiy I etin auymc IItOh IIto Y 1.nn.winq ,nolahun,
l �ltesiyruficanl ponalhc:, fui subnldhny f�Jsc: ndoinntic�u, uuaurhnt tlia ioe,ihdd of hnc� nn�l ini nronn�eni In
e- !] ' ,
Permittee (or A thoriz d Agent) Name and Title - Please print or type Signature of.Per t e u orized Agent) (Date)
mg/L Effluent Total VOCs: mg/L VOC Removal%
ca`
GW-59 ev.08-07-2018
3-36�a1

GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
FACILITY INFORMATION ` Please Print Clearly or Type
Facility Name: �qC hQek < t\-(A DY.
Permit Name (If different):
Facility Address:
Contact Person:
Well Location/Site Name:
SAMPLING INFORMATION —�y� ,,,,\\
WELL ID NUMBER (from Permit): \' �W
Well Depth:
SUBMIT FORM ON YELLOy1( PAPER ONLY
Mail origina
and 1 copy to:
County �c&ckQ.(1(, [
Telephone#: ` re 03 - 3ll3 `'
ODD No. of wells to be sampled: S
Date sample collected:
Well Diameter:
Depth to Water Level 82548: / a ft. below measuring point Screened Interval:
Measuring Point is of S ft. above land surface Relative M.P. Elevation:
Volume of water pumped/balled before sampling: gallons
Samples for metals were collected unfiltered: IN YES El NO and field acidified:
aft.
LABORATORY INFORMA ION
Date sample analyzed3 ) 3' 3-4 3' I —Q. Laboratory Name:
PARAMETERS NOTE: Values sh6uld reflect dIsiolved and colloidal concentrations.
COD 00335 mg/L Nitrite (NO2) as N 00815
Coliform: MF Fecal 31818
Coliform: MF Total 31504
(Note: We MPN method for highly turbid eamplea)
Dissolved Solids:Total 70300
pH (Lab) 00403
TOC mesa
Chloride 00940
Arsenic o1002
Grease and Olis 00552
Phenol 32730
Sulfate 00945
Specific Conductance mom
Total Ammonia o0e10
48
(Ammonia Nitrogen; NFyae N; Ammonia Nitrogen, Total)
TKN as N ooe25
/100mL Nitrate (NO3) as N 00820
(from Penult)
3s+-at
In.
ft.
to
ft.
YES ❑ NO
PERMIT Number:
Non -Discharge
NPDES
66xplratlon Date:
UIC
Other
TYPE OF PERMITTED OPERATION BEING MONITORED
lahgoon ❑ Remedlatlon: Infiltration Gallery
111' :pray Field ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
FIELD ANALYSES:
pH oo400s.1 units
ft. Spec. Cond. 00094:
Temp. 000lo:1e(t3 °C
µMhos
Odor 00085:
Appearance ��4. *ck \
U i-co c.\\UNN,
aL as
/100mL Phosphorus: Total as P 00885 SO
mg/L
units
mg/L
mg/L
ug/L
mg/L
ug/L
mg/L
µMhos
mg/L
mg/L
Orthophosphate 70507
Al - Aluminum woe
Ba - Barium 01007
Ca - Calcium mole
Cd - Cadmium 01027
Chromium: Total 01034
Cu - Copper 01042
Fe - Iron o1045
Hg - Mercury 71900
K - Potassium 00937
Mg - Magnesium 00927
Mn - Manganese o1o55
NI - Nickel 01087
mg/L
mg/L
mg/L
mg/L
mg/L
ug/L
mg/L
ug/L
ug/L
mg/L
ug/L
ug/L
mg/L
mg/L
ug/L
ug/L
Pb - Lead 01051
Zn - Zinc 01092
Certification No. 'k
ug/L
mg/L
Other (Specify Compounds and Concentration Units):
ORGANICS: (by GC, GC/MS, HPLC)
(Specify test and method #. ATTACH LAB REPORT.)
Lab Report Attached? ❑ Yes (1) ❑ No (0)
VOC 7873 , method #
, method #
, method #
, method #
If WELL
WAS
DRY at
time of
sampling,
check
here.
For Remedlatlon Systems Only (Attach Lab Reports): Influent Total VOCa: mg/L Effluent Total VOCs: mg/L VOC Removal%
certify 'co to iha beat of my ken fiedlte and belief h ut nfoiillation subnniletl in Hu. i nil c: lire a ; uiolr nnri cnuq k I ,utcl Ihal the I.11,1 ilr iy pinrinr_-c n Th in appiavcd in,athuds of analyse by a
MR -certified l abolatory I dm awalc lllal Iham yr: suit lflcanf ponaihe hut sabnniliacj frdse rnfonuotton. Inciudngl tlio ho::e,ibilily ❑i fu r=.- nncl nnl,,ronnr:nl fa r.iinrdntll wolntiuns
111,
gent) Name and Title - Please print or type Signature of.Per t a .Uorized Agent)
Permlttee (or A
GW-59
horize
08-07-2018
(Date)

GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
FACILITY INFORMATION
Facility Name:
Please Print Clearly or Type
SUBMIT FORM ON YELLOW PAPER ONLY
Mail original
and 1 copy to:
Permit Name (if different):
Facility Address:
---cakcl
(City)
Contact Person:
Well Location/Site Name:
(:dale) (Zip)
SAMPLING INFORMATION
WELL ID NUMBER (from Permit): \'�w_ �q l`
Well Depth: permit):
Depth to Water Level 82648S . /D\ ft. below measuring point
Measuring Point Is q� r S ft. above land surface
Volume of water pumped/bailed before sampling: gallons
Samples for metals were collected unfiltered: It YES ❑ NO and field acidified: ® YES ❑ NO
PERMIT Number
Non -Discharge
NPDES
1
36dxpiration Date:
UIC
Other
TYPE OF PERMITTED OPERATION BEING MONITORED
Iti-6egoon ❑ Remedlatlon: Infiltration Gallery
®-315ray Field ❑ Remedlatlon:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
FIELD ANALYSES:
pH oo400:rO n'f units
ft. Spec. Cond. 00094:
LABORATORY INFORMATION /
Date sample analyzed-t f $ -' 3- 6)) 3-/d 3 -1 / t Laboratory Name:
PARAMETERS NOTE: Values shbuid re#tact dislolved and colloidal concentrations.
COD 00336 mg/L Nitrite (NO2) as N o0816
Collform: MF Fecal 31618 .. % /100mL Nitrate (NO3) as N ooe2o
Collform: MF Total 31504
(Note: Use MPN method for highly turbid samples)
alssolved Solids:Total 70300
pH (Lab) 00403
TOC 00880
Chloride oos4o
Arsenic o1002
Grease and Oils 00662
Phenol 32730
Sulfate 00946
Specific Conductance 00095
Total Ammonia o0810 6 •
•
(Ammonia Nitrogen; NHsas N; Armenia Nitrogen, Total)
TKN as N 00825
/100mL
mg/L
units
mg/L
mg/L
ugiL
mg/L
ug/L
mg/L
µMhos
mg/L
mg/L
Phosphorus: Total as P 00865
Orthophosphate 70507
Al - Aluminum o1106
Ba - Barium 01007
Ca - Calcium 00916
Cd - Cadmium o1027
Chromium: Total 01034
Cu - Copper 01042
Fe - Iron 01045
Hg - Mercury 71900
K - Potassium 00937
Mg - Magnesium 00927
Mn - Manganese 01055
NI - Nickel 01087
mg/L
mg/L
mg/L
mg/L
mg/L
ug/L
mg/L
ug/L
ug/L
mg/L
ug/L
ug/L
mg/L
mg/L
ugiL
ugiL
Odor 00086:
Appearance
Pb - Lead 01051
Zn - Zinc o10s2
Temp. 0001o:1 Si aC
who.
Certification No. \4
ug/L
mg/L
Other (Specify Compounds and Concentration Units):
ORGANICS: (by GC, GC/MS, HPLC)
(Specify test and method #. ATTACH LAB REPORT.)
Lab Report Attached? ❑ Yes (1) ❑ No (0)
VOC 7873 , method #
, method #
, method #
, method #
If WELL
WAS
DRY at
time of
sampling,
check
here. r—i
For Remedlatlon Systems Only (Attach Lab Reports):
County ",bldke..c1
Telephone#F1(6 -c 3 ' 343
No. of wells to be sampled: ..
(from Pemllt)
Date sample collected
Well Diameter: _ In.
Screened Interval:
Relative M.P. Elevation:
to
ft.
mg/L Effluent Total VOCs: mg/L VOC Removal%
l'eeihfy (I'ia,t, In ihr hc,t of lily leuif^derhle .uid hcllt f. the iufoiivalinn sulnndlad in (III- Ifoit is hue a r ur.Jr: and conii I.,cud (hut the Inbolaloiy n)_ l,Ii ail data o proclucerI using approved melliods of analysis by a
u NR-ci:ihllcd I Ihoi[dnry ' ani nwale Ihal II rnr- S signdicanl penalties for subnnituig (case oifooneillon inrludm{7 llic nos_ ihiii) or tpies Foul milli i nur:nt fn lino ni viohilions
•
-
3
Air
Permlttee (or Au orize Agent) Name and Title -Please print or type Signature of. Per t e u orlzed Agent) (Date)
GW-59 08-07-2018
Influent Total VOCa: