Laserfiche WebLink
HINNESOTA DEPARTMENT OF HEALTH GROUND-HATER MONITORING - VOC SAMPLE/ANALYSIS REPORT <br />Form SSU-3 Rev. 9-85 <br />S. SAirtC IMFOMTIOH <br />SlU I.D. <br />Ntater <br />Collection <br />(kte 1 <2 9, <br />N N 0 0 1 T <br />Field Well <br />nmt^r <br />Jim <br />(24-hr. clock) <br />Uli las <br />ColIccUd by \ \ArsUi pStCiA <br />Water Systen <br />Name (Public Systeai) <br />Omer Wane TVvnv Mc I L OLv^xA ^ <br />FacHIty Address r- 11 \ <br />(St., Rte. or P.O. B ok ) /SO I^VC vj^lA l/c5q r\ <br />City and Zip Code Vfy_______S S. S<T <br />Sailpl^Type (check i^one) <br />Q-i^ntreated Mater <br />Q T Treated Mater - Treatment Type, <br />Q 0 Other_______________________ <br />SanpHng Point Description <br />PsaTSlop. ravAf<^ S^oj\\a <br />Analysis Type (check w^one) <br />Initial Sample <br />(□ 0 Other______________ <br />Split Sample? <br />f~) C Check Sample <br />□ Yes Q-^Mo^ <br />Lab Budget <br />Niflber <br />Lab Sample <br />Number <br />Date <br />Received <br />Date <br />Confirmed <br />iMNl^Jol cM <br />I 7 O e|q 6. <br />0 1 ^s. 7 <br />M M 0 0 f / <br />M N 0 0 Y T <br />Field Blank <br />Number <br />Date <br />Analyzed <br />) bbNqis. <br />OaU <br />Refiorted <br />M M 1 0 0 Y 1 r <br />1 o <br />H j M 0 0 ^ ^ <br />I. PAMICTEt AMO CONCCNTRATIOII INFORMATION <br />Q^^alysls Requested - Volatile Hydrocarbon - Code 465 <br />YOC's Detected? Q Yes pfNo <br />Code <br />acetone <br />ethyl ether <br />benzene <br />toluene <br />cumne <br />m-*ylene <br />tetrahydrofuran <br />methyl ethyl ketone <br />methyl Isobutyl ketone <br />ethyl benzene <br />o-*ylene <br />p-xylene <br />chloroaie thane <br />vinyl chloride <br />chloroethane <br />d 1 ch 1 orod 1 f 1 uo rome'.hane <br />broanmethane <br />d1ch1orof1uoromethane <br />methylene chloride <br />allylchlorlde <br />1.1- dlchloroethane <br />c1s-l,2*d1chloroethylene <br />l,2*d1chloroethane <br />1.1.1- tr1chloroethane <br />bromod1ch10romethane <br />2,3-d1chloro-i-propene <br />1.1- d1chloro-l-propene <br />I,I,2-trichloroethylene <br />° s □ [] <br />□ C]□ m□ o □□□□□□□□□□□□□□□□□□□□□□ <br />Result (ug/l) <br />[]_________ <br />C3_______□____ <br />[]_________□____ <br />C]_________ <br />C]________□____ <br />C] [WOT QOMTIFICDl <br />Cl [SOT OUMTIFICD] <br />□ isoTjuMmttoi <br />Cl [WOT OUanTIFltD] <br />ci [WTjJUfmTJTICOl <br />Cl rWT QUMTiriCDl <br />Cl________□ ____□_____□_____ <br />Cl_______ <br />Cl_______ <br />Cl_______ <br />[]_________ <br />[]_________m_____ <br />Code VOC <br />chlorodibromomethane Cl <br />cls-l,3-d1chloro- <br />l-propene Q <br />2-chloroethylviny! ether <br />1.1.1.2- tetrachloroethane CD <br />1.1.2.2- tetrachloroethane CD <br />pentachloroethane CD <br />1.1.2- trlchlorotrl- <br />fluoroethane CD <br />1.2- dlchlorobenzene CD <br />trichiorofluoromethane CD <br />1.1- d1chloroethylene CD <br />trans-1,2- <br />dlchloroethylene CD <br />chloroform CD <br />dibromomethane Q <br />carbon tetrachloride Q <br />dichloroacetonitrile CD <br />1.2- d1chloropropane CD <br />trans-l,3-dichloro- <br />l-propene CD <br />1.3- dlchloropropane CD <br />1.1.2- trichloroethane CD <br />1.2- dlbromoethane CD <br />bromoform Q <br />1.2.3- tr1chloropropane CD <br />1.1.2.2- <br />tetrachloroethylene CD <br />chlorobenzene CD <br />1.3- d1 chlorobenzene CD <br />1.4- d1chlorobenzene fD <br />Result (uq/1) <br />Analyses <br />Requested <br />□□□□□ <br />Code Parameter <br />Result (mg/l unless <br />otherwise noted) <br />i2-*=±Q.nltrate^nltrlte nitrogen <[ <br />ammonia nitrogen _____ ^ <br />chloride _ _ _ _ _ _C <br />sulfate ~ZZ±-S <br />Analyses <br />Requested <br />□ <br />□□□ <br />Code Parameter <br />specific conductance <br />pH <br />Result (mg/1 unless <br />otherwise noteo) <br />.:z:zQ-_ _umno/c«.