Organic And Inorganic Chemistry Sample Submittal

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New Jersey Department of Health
Field ID Number
Lab Sample Number
Environmental and Chemical Laboratory Services
(For Lab Use Only)
PO Box 361, Trenton, NJ 08625-0361
Phone: 609-530-2820
ORGANIC AND INORGANIC CHEMISTRY SAMPLE SUBMITTAL
(See Instructions)
AGENCY INFORMATION
Submitting Agency
Send Results To
Agency No.
Project Name
Street Address
Final Report Option
Would you like copies of the internal
Project Code
chain of custody forms sent with
Tier 1
Tier 2
your report?
Electronic Report Option
Memo Number
Yes
No
EDD
E-2
City, State, Zip Code
Phone
Fax
Email
SAMPLE INFORMATION
Sample Point/Station ID Number/Water Facility ID
Collection Date (YY/MM/DD)
Sample Type
Non-Potable:
__ __ / __ __ / __ __
Stream/Surface
Tissue
Sampling Site/Facility/Supply/Location/Sampling Point ID
Coll. Time (24h) Start
Coll. Time (24h) End
Ground Water
Sewage:
__ __ __ __
__ __ __ __
Private Well
Raw
Effluent
Waterbody Name
Sample Retention
Septic
Industrial:
Ocean/Saline
Raw
Effluent
________
Retain?
No
Yes
Duration
Sediment
Municipality/County
Type of Sampling Event
Potable:
Regular
Compliance
Repeat
Groundwater Rule
At Source
Non-Regulatory
Other
Source
Flushed
Sampling Point Street Address
If Repeat or GWR, List Original Lab Sample No.
Confirmation
1st Draw
Raw
Lead Source Line
Finished
Surface H
O Intake
Sample Collector
2
Private Well
Distribution System
Fraction:
Total
Dissolved
PWSID
Trip #
________
Other:
Priority:
Routine
Priority
Emergency
FIELD INFORMATION
Air Temp °C
Water Temp °C
Stream Flow-CFS
Weather Conditions
Sample pH (Field)
Gage Height-Ft.
DO (mg/l)
Spec.Cond. (µS/CM)
Preserved in:
Field
Lab
__ __ / __ __ / __ __
Date:
DO% Sat
Salinity (ppm)
__ __ __ __
Time:
Chlorine Residual
Sample Depth Ft.
Tide Stage
Comments/Field Checks
Barometric Pressure (mmHg)
Turbidity (NTU)
ANALYSIS REQUESTS
Metals
General
Organics (Drinking Water)
Ag ............... Silver
Mg ..... Magnesium
Alkalinity
Fluoride by IC
EPA 504.1 - EDB, DBCP,123TCP
Al ..........Aluminum
Mn ..... Manganese
Bromide by IC
Hardness
EPA 505 - Chlordane
As ............ Arsenic
Mo ... Molybdenum
Chloride
MBAS
EPA 505 - Toxaphene
B .................Boron
Na ............Sodium
Chloride by IC
Odor
EPA 507 - N and P containing Pesticides
Ba ............. Barium
Ni ............... Nickel
Chromium, Hexavalent
pH
EPA 515.3 - Chlorinated Acid Herbicides
Be ..........Beryllium
Pb ................Lead
Chromium, Hexavalent by IC
Phenols (PW)
EPA 524.2 - Purgeables
Ca........... Calcium
Sb ......... Antimony
Color
Phenols (NPW)
EPA 525.2 - Liquid-Solid Extractables
Cd......... Cadmium
Se ......... Selenium
Conductance
Sulfate by IC
EPA 531.1 - N-Methylcarbamoyloximes and
Co.............. Cobalt
Si................. Silica
Cyanide
Sulfate Lachat
N-Methylcarbamates
CR-T.... Chromium
Tl ............ Thallium
Dissolved Oxygen
Turbidity
Organics (Non-Potable Water)
Cu.............Copper
U ............ Uranium
Fluoride
Mercury
Fe .................. Iron
V ..........Vanadium
EPA 624 – Purgeables
K ..........Potassium
Zn.................. Zinc
Mercury by EPA 245.1
EPA 625 - Base/Neutral and Acid Extractables
Preferred Methodology
Low Level Mercury EPA 1631E
EPA 200.7 / 200.9
EPA 200.8
Nutrients
Demands
Residues
Nitrite
Nitrite + Nitrate
Total Organic Carbon (TOC)
Total Suspended Solids (TSS)
Total Phosphorus
Ortho Phosphorus
Dissolved Organic Carbon (DOC)
Total Solids (TS)
Ammonia
Total Kjeldahl
Chemical Oxygen Demand (COD)
Total Dissolved Solids (TDS)
Nitrate (Calculated)
Nitrogen (TKN)
Suggested Dilutions
Settleable Solids (SS)
Nitrogen, Total (Calculated)
Total Volatile Solids (TVS)
____ ____ ____
BOD5
BOD20
Other
____________________
____________________
____________________
____ ____ ____
CBOD5
CBOD20
Relinquished By:
Affiliation:
Received By:
Affiliation:
Date/Time
Reason for Custody Change
Name (Print): _________________________
Name (Print): _________________________
Signature: ____________________________
_____________
Signature: ____________________________
_____________
__________
_______________
Name (Print): _________________________
Name (Print): _________________________
Signature: ____________________________
_____________
Signature: ____________________________
_____________
__________
_______________
CHEM-44
FEB 16

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