Document Yj7dd27brYRw6vvxMYVXoQrQ8
~treel No.
Name
rematrein 9018 Slephen Chlebeck & Pat Etarrett sng ,./ 9038 William & Ftlen Hu~hes
Y| ot tres 9046 Keilh & Susan Weiand
T=|rB t EpE e 90~1 ~r~ >| w+r msomet----e 9077 John Sandstrow~
dow
Phone ~ Well Oeoth Aaulfer ~ S~ml~le Date Samz)le Collecte~
General Comments
voohrweee pa mCnrAtR00ep 8dLy BA wn -- me"y"eP sfusr e 0014m h52 emnna mee wae wm 777-5046 604274
135
wa -- od te D0 evens 748-366z s2w0tol~ ~ O '"~
ose OPOC --
wn eX Yes 90
UCno lisS,gs in Wash.Co.
bypass softener, has. a sed. Filter
~5 Ch~st~her& ~sa
779-0331 62W01005
9098 Thomas Fdeddch
777-0113 82W01024
Yes
9141
or91#8
| wo
| oe~2
Tow|oe92~0
Theodor# Slerbenk
mstenr-- Donald Delander
EH ~&MI~I~ ~1
GEE on
~ --
770-4177 8,?.W01006
ymut--i _i--E -- 777-5883 82W01007
EDLY~65~ we ~01023 tr
fr 6H~698
100
OPDC
Yes
-Yes ww
or Yo lds
Te Yes
ee WO
essen
Wez0w028
9343 9345
BE9~5 |g~
Pau~ & Chadene Fdeddch Jin & Nancy Fdeddch
EEG 8~in & ~ene ~ip~e CT Gg ~d J~n~n ~
777-2201 777-6424
Jee~-~
82W01009 82W01020
~99
re thinks I50
118
0
UNK
Yes
R am pYe 'l~lik to Fre~dch~'
mm listed ir~ Wash. Co. list
ilsle~l in "~earc/~bug', r~qte~ mail; 14926 Paul Ave=, Mar[neon St. Cm~x 55047
ss tad W sk~e of h~Jse, yd hydr~.of rare tap N side of house oom tap E ~de ol house a eeTrE no o,~ide taps - neeQ ~o set u time to meet
taps fmnl a~d buck, reave into aboul s~mple E lap, leave into on VOC/N/bact Test~n9 taps W, E, $ sides of house
tap [oven behind house
wm tap in back of house (dc~'t use I~,nl tap)
several t~ps
~o't ~nd ~e~ to ~em ~ldnl le~ ~, ~ ~
.
Wee 3% 5. - Russell + Lovi gefocher (seek saugp 2053Toney
z
Lrorens haune,
T703137)
{
reuts fo boo Met~ihu efo.s
1955
1955.0001
1955.0001
1 [I retire] [E MDHChain Y oPfYCuSsEtody Minnesota Department of Health
Chemical Laboratory 717Delaware Street S.E.
BN EE, [tanhise Minneapolis, Minnesota 55440
> | [FPeotrenatilalHHaaazarrd: YVee~lm,a/dk::~m/Uonkwnownn (CCoirccteOOvneer)
pe ee If Yes: Chemical/Biol0gical!Other
~"'~"~x
= ConofCoty GoceOv bn ean ~_land.~d.~d~Civit/Criminal Chain of Custody
(Circle One) (Circle One)
Site ID
Sampl~ By
Sampler Signatore
TT
M moDnH liO000002 211 9~ 94
tm lFemiibs6% Di ro ~y 499
Address if Nc~ded.
=-=SAMPLER COMMENTS
Field [D
Sample Source/Point
Time
MDH Sample
Matrix
(24 Hour Cl~ck)
Number (Lab Use Otdy)
Hiae mrreT Problo TTwe 1
[HGrTs r,Lf
e[HaaahmipeSsdeorsaeorTe Tnefeia o TToo T TTHHTe TSee der
eS Ie [Bacest rue30 or |v hres" Jw [TIM 00 7
[colaeSar dseTr oe Tor olpTomo T p mTmTTbe ot e f ) ]
zEfe SAMPLER COMMENTS:
RECEIVING COMMENTS:
LAB TEMP
C
rai SEAl. INTACT: YES / NO
TIME
DATE
ACCEPTED BYIAFFIALIATION
E8R Eatea r a r d] btueC an B1 ald e foegde eggare Dl --eeeemm------)| ' "~;' z~ <; ..,: /t. ::,-~ A /, f " II
-::~J,~,9,,~',! ~I(A",r:-";-.,F.~!/I.,::;~=." ~t,-.,-
I White Lab Copy
Yellow Client Copy
Pink Submitter Copy
DATE
Joss 0cz 1955.0002
t + amtn eE mcrosOosmS ngorIcNu YL B E E C CAC D R 0S ) SrEiC eCtCC ontre nhamar.o msi teebnrs ee
ete.
!
76. CRoiSttaEec mwoveo aes n ees oeetSETTERRHE ProgramCo 2 isicr) BudgetCodefoundi theMDHChemicalLaboratory Handbook
11 BSdti omeeinteomet ee simie
sat iSewierno ------rt
1 Sma. smi tone
:
14. Ell - Keotificationonbottlesmustmatchthisideoification(rambersor eters).
1A15.
-- som-- ome--e" t ire SamplingPoiatSeures -Wordsorumbersused i identifythe sc.
-
N00he
1i H naee SesrotPmrs eeantse, OH
S7t ee ereee teenee rtteA: tand
A --
BS na ec ek TALEETLRO
Cn 2E BiEcp R50o07Anr e oim pe ty
1 setarevmeren etm------
1*7.Bae E m aEeeresaemrte sat titrteeeHR ma mooiI t OetpHaeCeetot nre mteeor sn ete en or 28. JemNo.-IndicatewhichFiekd/SitchyouhavesubmiticdtoMDHLaboratoryforanalysisby temsuber(77)
11995555..00000033
MMNN..330033..00000033..000000006622
A I E Minnesota Department of Heallh
Chemical Laboratory 717Dehware Street S.E.
| i, |reekGonE Minneapolis, Minnesota 55440
mr oer seo] t~o~
[Fem Te COT pregame gn QM) Potential Hazard: Ye~nknown
(Circle One)
MDH Chain of Custody
CtienffAgeney~ ~ (~ ~- { ~\ ~}
Site ID
fB ons s cuntwsaa Ranh, CchemicaltBiologicallOther ~ coo STH ivil/Criminal Chain of Custody
(Circle One) (Circle One)
mlSampled By (Print)
Sampler Signatu~
Ae
Number of Containers
wor 1902195
Reto tFhocghyanleh
Fly ror
SCont ey {lngrmor
--
-- Address if Needed SAMPLER COMMENTS
Figen]
a3
i [== Field ID
Sample Somc~'Poiul
Collection Date
MMIDD~YYY
MDH Sample N~mber
(Lab U*e Only)
Matrix
-
EE [[[ fsoeuyf9o0t30a2mo 5HPlioefewaJliaoaael||r Twoeoo T[[TJTt TIOMKIT]dTe TiSdeagehh naddon= o ]|
[h[ammstfbeiontsei3eaTTwolael TToo TTTTTTTh eeri oe en]
[P56' ehsaorsosre TTnolJuse IT= TTuu TTITTRRd AG e A e] ]
7~
A8 kron3s |0(w~,o.~
Lo [TTR
aebahseee,
|
9
M1
71room
10
SAMPLER COMMENTS: RF_.~EIVING COMMENTS:
LAB TEMP __:C
Pre ----Tr] ITEM NO.
,.RELINQUISHED BY/~A..F.FIALIATION /
8IL Se m-- re r = er ePr = aa epere r WhileLabCopy
Yellow Client Copy
SEAL INTACT: YES/NO
DATE ....
se 1955.0004
STATIONSFOR FLING OYTHENH CHAROF CUSTODYFORM I~,ISTRUCTIONS FOR FILLING OIflr THE MDH CHAIN OF'CUSTOD~/FORM FRE om pI il , aee Potenfialttazard - Identify potential hazard by circling one of the choices (Yes. No, Unknown),
2 id Cinoneetebis If Yes - Circle one 0fthe choices. So poCi CLO Sit ut Coy tt S;pndard/Civil/Ol~her],Crim ma (~hain of Custody (C arc~, - The "Standard" Chain of Custody is used for marine
samples, The "Civil" and "Cri.~nai" Chain of Custodies .are ~ed for ~amples which have the potential tQ be used in court
Comb CottCoty amg ed wnt cases. There is an additional charge assi~a:d for Civil ahd Crimin~ Chain of Custody ~.amplcs
Ce hm lni woon s o drs : Cllent/A~eatw - Print ~e Client/Agency ~Ito should receive the results.
5 BcSamc iepoemt tne mere. : Proiect Name/# - Print the project and/or cost code number here,
[------ Silt iD - Print the site ID number~
BranCoteusCoe nn MMC Ler dk Proiram C0,dtq 2 letters~ - Budget Code found in Ule MDH Chemical Laborato~ Handbook.
7. Cam m-Whotcstspin eins vtesl 7.
Name-Who to contact regarding questions about the samples.
+ Coenm e tp emea en Contact Phone - Phone number ofthe contact pcrson~
5 MPIYSAN Mit epoch CC se DO NOT WRITE OVEROR CHANGERS 9. ~ - Minnesota Department ot'Hcallh C ol'C number. DO NOT WR ITE OVER OR CHANGE ~J'I-IlS FE NI.IMBER.
10 Bm tae sto den ee bn epse 10. ~ - Print the name .and address of~h client to receive the report only if t.k~se are special arrangement ~ampls and/or
have a LN program code.
"
1 . Sam btSalyoererbe Samaled by (Pdnfl- Sampler(s)please print your name here.
12 an py Fii no cliot dses Alliliafion~b0ne -Print Agency o'r Firm you are collecting them samples for.,
Pas.Sos rent. l~ilgne - Sampler's phone number.
13. Semee c rn ye ine 13. $nmoler Si~ntlure - Sampler,s) ple,a~e sign your name.
14. Bl" erme a is fc in et sr Field ~ Identification on bottles must match this idantifieation (numbers or lettr~;L
15 Samal SoeWsants mo sty es ~
"n P :n
r .Wordsornumbctsusedtoidenti~'thesite.
16 Dat Motto ot ect cme OV) 16. ~ - Mol~th. day and year collectect (example 01/13/97). 17 gt oe Tino ot re on pe ke AM. 10810 17. ~ - MIlitih'3 Time (24 hour elor,,k,~ for the hour and minute the sample ,was coileulcd. A.M = 0000-1200; 0110 would be
I:t0 a.m.
J P.M. ~ 120 [ -2400; 2200 would ~ l 0:00 p.m.
18. MMDDHFSI SaammpolteNNuummbebrer(LLaobbuusseeoonnllyv}b PPilceaasseeDDoonnoottw~rvirtietei:hnt tihhiissa~rers~,T"hFinsisisisffoorrMMDDHHIlaabbuusseeoonnllyy.,
19. Mais Sue pe wi ts ms, 19. ~ - Samph~ type, i.e,water,~oi[,air,fish,sladge,pig ma~ure, etc. 20 NambaCnes By be ed erof rss arch 20, Number of Containers - By bottle type the number of eontainer~ submitted for each site. 3. TantaCommas or che che es eshd.) 21. Tolal # of Cun;ainers - Fo~ each site picnic place the total number of bottles submitted.(~) 2 SeamsPea pesct rc ot af es lp 22. ~ - Please plat a check mark in the ver~cnl boxed area for those samples whi~ have an
23, Slanted ~x a~= - ~0~ ~ples ant ~quidng an additional p~eter sh~L list ~ malytcs and ~st ~d~ ~u~d for
Ta ose ca~ s~ple, Ple~c no~: If~cm ~ n~mero~ ~al~es ~ ~itiona~ p~emr 5beetis mquesmd.(??).
20. Sym Compe csv nde ey ste OTSANPLLS GASPULL LL ODOR 8 24. ~qsmuler Comments - Pkase use this space to indicate any po~sihie "HOT SAMPLES",'OAS/FUEL OIL ODOR", or a
METALS ~mple that wa~ FILTERED.
0 oer come teste Use the second area of sampler comments if needed,
:
2 BeinComets DONOT eatse i 25. ~ - DO NOT wri~ in this space. 2 pensop cmpee so ee iy 26, Lab Temtt - BOD or fecal c~lliform sampk:s; record tcmFeramre reading from s~mpling cooler up0a dctivcw to MDH
Sample Entry area - thermometer is by th~ sink in room 502B.
1 Salle eBstr Seal intact Yes!No-.For MDH use only. Do not write in this area, . 2 25. mt te FS or ee MDHAcres mis bm es) 28. I~ NO..- Indicate which Ft~ld!Sit~ you have submitted to MDH Laboratory for tmaiysis by item number.(??)
RB ela AnsS dom 5 . 29. Rdinauished Bv!Afli|i~tio~ - Sampler signature and company/agency. 30. Baek alee | 30. Dat~e - Date sample relinquished. 31. Tinie ts elopMOMeChdem., "~iJl~ - Time ;amples relinfluished to the MDH Chemical Lab.
2~2. Aoeeoltd By/Affiliation - Courier delivering your samples to MDH Laborato~ sign bet . Also sign the" Relinquished By/
Jl ttTego obey re Affiliation" line when ~e sm-nples am delivered to the MD|t Chemical Lal~rator~. The samples wilt be signeM for upon
eT eof Gets Coin receipt at MDH Laboratory by adesignated Chem Lab Chain ofCustody Custodian. 2. Bar uals venticom. . 33. Dat~ -Date sampl~ dallvered or given to courier. = Tare------------ Time - Time samples deliver,d to MDH Laboratory or given to the courier, 5. ytot fot es White Cotw of form to Client - White co~y of the Chai~l of Custody with the re~ults reported to t_,hc client.
YI]o_w ~6av of fm'm tO MDH Lab - For MDH Lab use.
in eve. vo Pillk.CoDv of Form to Samnler - Given to th~ person delivering the sample.
11995555..00000055
MMNN..330033..000000330.00000006644
MMiinnnneessoottaa DDeeppaarrttmmeenntt OOff HHeeaalltthh
PPrreelllimm~innaarryy RReeppoorrtt -- CClliieenntt CCooppyy -ProgrPaPrmroogNgraeamnma::! aWQPrWCA CLOSED LAMDYILL AssEsmET Program Name: MPCA J CLOSED L~NDPILL ASSE~SMET
[iaSaammpptleens:: 20000041299996860-- 220000043139997766I
see mo >Site
wPPrraoosjjneeccctto.NNaassmueer
WASH CO. SLF
-- EEnnvviirroonnmmeennttaall LLaabboorraattoorryy
RReeppoorrtt OOFf AAnnaallyyttiiccaall RReessuullttss DDaDatatteeeGeRRneeeccreeaiitvveeeddd,:: 222060---J09~v7rLL-.--222000000448 DatReeuGesnseraPtaegde:s 1 of 8 26-JET~-2004 oRwenqueFsatpoPangde: 1 of 8
Date Reported:
oSsnaempperlseesdaenByy
JZM KELLY
[ampleto: 200419968] Receiving Comments: ~mUvGaHuEEsS
iSample NO: 200419968I Receiving Comments:
SCCooo-llrlli-Dbazatoetnse__ cCoollll10TT3i0immee FFiieellddi wNoo
Uunnitqauee SsniitteenI1D0
20-J~L-2004
1020
1
trip mlank paola man
Wel Common Name 903S 31ST ST
Trip -Blank 2F02i00e40l4d1199B99l77a66nk
Well BCommon Name
tte: onewze cummeray
Unit: ORGANIC CHEM-/STRY
Nota: Positive Organic Remit axe indicatedRRbeoysus2li0t .
555533NotsPerrF:ooOssSP//ooPsrFioOtnAivsienn
ater Organic
Water
Results
are
i~=~ted by BOLD.
< os
rPPFFoOOnpSAeak present; ast cnc 0.4 ob
pA ~ 0.5
< 1.0
peak present; est conc 0.4 ppb
RReepptt Lleevveell Units Units
0ov.so5 vuege/mnL
1.0
ug/L
AAnmaallyvsaitss DDaattee 53-200
Group 26170 Sle sage 1 of 3
Group 226170 Sample Page 1 of 1
1199555..00000066
MMNN..330033..00000033..000000006655
MMiinnnneessoottaa DDeeppaarrttmmeenntt OOff HHeeaalltthh
Prelintoasy Report - Client Copy -
ProgeapPrnrooggNreaaammne::.
NQoPvWPreAliCmLiOnSaErDy
Report -
LADPILL
Client Copy
ASSESSNET
-
Program
Name: MPCA
Samples:
CL2OS0ED0I~4KN-D1F2I90LL098Ao1So63S9ES07B6M~T
Samples: 200419958 - 200419976.
st3em
Pwrraoospjeeccsto.Ntaasmmteer
WASH CO. SLF
-- EEnnvviirroonnmmeennttaall LLaabboorraattoorryy
Report Of Analytical Results
Report DOaDDftaaetcAeenCaaRRlneeyacctreeiaiictvvaeeelddd:::Re222s006u--.lJ75tU01sL1.--222000000444
Date Generated:
a Roquast rage: Request Page:
2 of 8 26-~qrL-2004 2 of
Date Reported:
sawSmamppmrlaeedaysByy'
JIM KELLY
a ISampmle nNoop:: 2l 200001411e93996693i| RReecceeiivviinngg CCoommmmeennctes:: WEA WELAND
CCoollll DDaattee _ CCoollll TTiimmee
ozo de 2 20-J~L-2004
1012
FFiieelldd NNoo
2
Tip !Blak p2e0l0a019m9a76me Trip Blank
Field Blank 200419976
~~. UUnniiqquuee SSiittee IIDD
oot mot 9046 31ST ST Mel Comon ame Well Common Name
=_
mie: oxawrze crmxemx
~nit: ORGR~IC CKEMXSTRY
Note: otive Organic Result axe indicatedRRbeeysmu2li0t10.
Rept evel aits
Rept Level Units
Amslveis vate
Analvmls Date
555533.NotpPrevF:o0Os8SP//omPsFRiOotAniviienn
water Organic
Water
Results
are
iDdlcated by BOLD,
os
os wan
s2emnzons
23-J~L-2004
rPPFFoOOppjSAneeaasnk gpprrreee~ssenpe~tn;iecesot~
cone
conc
0.3
0.2
gp.
ppb.
ote t<<PhaEs01..t50his 4 below01i,.to50he lowerUuw~gJa//inLLmi of ave calibration
Note that this is below ~he lower limit of O~r calibration
c~rve I0.25 ppb) .
Gop 670 Swple mage 1 of 1
Group 226170 Sample Page 1 of 1
11995555..00000077
MMNN..330033..00000033..000000006666
Minnesota Department Of Health
M~nnHsota Department
regen arnetintocy Saport - Preliminary Report -
Clink Coy - Of Health
Client Copy -
Program Name: MPCA CLOGRD Z~%I~DPILL AGGESS~T
gins I_S_a.~_~ap__l_es:
Site ID -
ti 200419968 - 200419976 Project Name WASH CO. SLF
- Environmental Laboratory - Environmental Laborator~ Kost. of Alysica Rema Report Of Analytical Results
J Date Received: 20-J~L-2004
Date Generated: 26-u-~L-2004 Request Page: 3 of 8
RE" Date Reported: Sampled By JIM KELLY
I[~psleaNNoom :: 2p 200004l 411999e97?00|]RReecceeiivviinngg CCoommmmeennttss:: SANDSTROM
Cell Date 20-JUL-2004
Trip Blank -
Cell Time I010
Field No 3
Field Blank 200419976
Unique Site ID 9077 3~ST ST
Well Common Name
[E-- EN Result soe smn Sg ames sin pn Note: Positive Organic Results are in~t~ca~edby BOLD.
553 PFOS/PFOA in Water
fod Ces es wn PFOS ne ER PPOA pres nc03e peak present; ~st conc 0.3 ppb
< 0,5 < 1.0
Rept Level Units
0,5
ug/L
1.0
ug/L
--. Analvsls Date
23-JILL-2004
ERR Group 22617@ S~mple Page 1 3) of 1
11995555..00000088
MMNN..330033..00000033..000000006677
aestsseseessesPsREeLeIHrIeARsY REPORT vesvevererenss
MMiinnnneessoottaa DDeeppaarrttumneenntt OOff HHeeaalltthh PPr~eelliimmiLnnaarryy RReeppoosrtt -- CClliieenntt CCooppyy --
ProgrPaPrrnooggNrraaamnme::. aMQPWCA CLOOED LANDFILL ASSRESNET Program f-- Name: MP~A CLOSED I~%NDFILL ASSRSS~T
[Ssaammpplreess:: 22000044129396688 -- 220000401299957766
_sSiitte-erImD
pPwrraoosjjheeccctot.vNaasmumeee
WASH CO. SLF
-- EEnnvvilrroon~meennttaall LLa~bboorraattoorryy
RReeppoorrtt OOff AAnnaallyyttiiccaall RReessuullttss
DaDDtaaetteeGeRRneeeccreeaiitvveeeddd::: 222060---J97UvLL1---222000000444
Request Page: Date Generated: Request Page:
4 of 2G-J~L-2004 4 of 8
ike Sgoriots
Date Reported:
_ ESsaemrppileegddsByy JIM KELLY
I[SsamapmleplWNeoo:: 220000441199997711]] RReecceeiivviinngg CCoommmmeennttss:: mKAAUUSSEERR
2CC0oo-ll5ll0-DD2aatt0ee08_ CCoollll10TT4ii5mnee FFiieell.dd Noo
Uunnii5qq0uu7ee8 Ss3ii1tt5ee7 I17D0
_
20-J~L-Z004
1045
4
9078 31ST ST
TTrriipp -BBllaannkk FFii2e0el0ld4d13BB9ll7aa6mnke
Wel) common Name __ Well pCommon Name
200419976
att: onaare cumezsTRY
Unit: ORGAniC CHE~XSTRY
Note: Positive Organic Results ars indicatedRRbeeyssuuBllOttLD. RReepptt LLeevveell UUnniittss AAnmaallvvsaliss DDaattee
Note: Positive Organi~ Results are IndLca~edby BOLD.
553
553
bpPrrFooOssS//BPrFoOnA
tn
in
Hater
Water
< os
os worn
22-00-2000
23-J-JL-2004
sPPFiFOoOpSnAeak presen; est conc 0.2 ppb.
<par0.eS
00.5
usgoiiLt
Note t<hat1,t0his 4s below1.t0he lowerugl/iLmit of our celibration
pC=ueurarvvkee.pr~1e00s..e22n55t;ppppobe))s.t conc 0.2 ppb. Note that this is below the lower limit of our calibration
GGrroouwp 2222661177~0 Ssaammppllee Paag~ee 11 ooff 11
11995555..00000099
MMNN..330033..00000033..000000006688
MMiinnnneessoottaa DDeeppaarrttmmeenntt OOff HHeeaalltthh Preliminary Repost - Client Copy -
Progra: anPreliminary Report - Client Copy PPrrooggrraaPmmrogNNraaammmee::: WQMPPWC~AA CCLLOOSSEEDD LI~A%NNDDFFIILLLL AASSSSERSSSSMN~ET
I samplers 200419968 - 20042597|6
SsieteeIrD --
project nase wPWraAoSsjHuecCctOo..NasSmuLeFr
-- EEnnvviirroonnmmeennttaall LLaabboorraattoorryy Report Of Analytical Remulta Report ODfatAe/~Raelcyetiicvaeld:Re2s0u-l7t0s-2004
DDaaDttaReeteequGGeeeRsnneteecreraiaftvtaeeegddde::,: 222606--5JJ-~Ur2LL-o0-2f200000444 8 sRheeqeueSsetparPnasgte:: 5 of 8
Date Reported:
_ samreamy Tn ray Sampled By
~IMKELLY
~[sample to: 200413972] Receiving Comments:
_bERGSTRON
BERGSTROM
9~2pCCloo0ell-llN2DoDa0:atet0e8~_0041cCSoo9ll7ll120]TT5ii8RmmeeceeivFFiiineeglldsdCoNwmooments:
nUiniq5q1uu9ee8 Ssaiut6ie7 cIoDTeso
20-JOL-200~
,1055
5
Teip Blank piel Blank
wel) Commontams 9198 31ST ST
Trip -Blank F2i0el0d419B5l7a6nk
Well Common Name
-
200419976
[pp
Note: osttive Organic Ramis are indicatedRRbeeyssuu2ll0~tD.
555523.NotP0erPr:oO0sS8P//oP0sFriOOtAniviienn
Water Organic
Water
Results
are
indicated byBOLD.
< os
sPFoOSx
<pa 0.5
PFOA
< 1.0
Rept Level Gaits
Rapt Level Units
o0i.so5 vwuga/nnL
1.0
ug/L
Asalveis Date
Ana!veis Date
25-2004
23-J~L-2004
row 226170 sample page 1 of 1
Group 226170 Sample Page 1 of
11995555..00001100
MMNN..330033..00000033..000000006699
ny waver smeeaneeas
MMiinnnneessootta DDeeppaarrttmmeenntt Of HHeeaalltthh
PFrreoll~imnt~onaarryy RReeppoosrtt -- CClliieenntt CCooppyy -ProgtaoPnrroogNgraeamnmes:: WoQPnWCA CLOSED LADPILL ASSESNET
Program Name; MPCA CLOSED LA~DFILL ASSESS~ET
uSammpptleens:: sSiete: mID
220000441193936688 -- 220000481199997766) parsotjeccto.nasmier
WASH CO. SLF
- Environmental Laboratory
RReeppoorrtt OOff AAnnaallyyttiiccaall RReessuull~tss DaD[ taeteGeRneeceriavteedd::-- 2206--J3E1L--22000044 DatReeq~uansetrartaeged:: of 8 26-~;UL-2004 SRaetequeRsetpoPratgeed: 6 of 8
Date Reported:
FsSapmply leedeBny~
JIM KELLY
ample wo: 200113973] Receiving Commenter mE.
~.~p~l$_~o! . 2~~ Receiving Comments: UNK.
CCoollll DDaattee
Soesicsoot 20-J~L-2004 rep Blak Trip Blank
CCoollll TTiimmee FFiieelldd NNoo
ros . 1105
6
tela mask Field Blank
UU niqn ue Si SiitteeqIDue
Saco sis st 9260 31ST ST well comonmass Well Common Name
_
-
200419976
.
[A
--
Notes Portiva Organic Resta axe indicatedRRbeeysmu3il0tt3.
Rleepptt lLeevveell Gates Units
AAnsaallyvseiiss DDaattee
553. orroors/eron in Note: Post~ve
553 PFOS/PPOA in
acer Organic
Water
Resul~s
are
indicated
by BOLD.
os
0s wn
aseneaoos
23-JUL-2004
PoFOnepn Aetak ppl rreesseenntts ;s eesnt
cons
conc
0.3
~.i
pb.
ppb.
Hoce sL<<eath01..t50his 48 beiew01Y..os50owe loweruuu@gB//niLLt of our culibravion
No~e ~ha~ this is below ~he lower limit of our calibration
curve (0.25 ppb).
Group 33670 comple ge 1 of
Group 22617~ Sample Page 1 of 1
11995555..00001111
MMNN..330033..00000033..000000007700
eetr--to----gANETIE HOT mae"
MMiinnnneessoottaa
DDeeppaarrttmmeenntt
OOff
HHeeaalltthh
-
EEnnvviirroonnmmeennttaall
Laboratory
Laboratory
Proltntancy Report - Client Copy - Report Of Analytical Results
ErogriP[nrogHra--anme.:
Preliminary Report - Client Copy
NQWECA CLORED LANDFILL ASSESSHEE
-
Report DOaDSfcaaettAeenGaaRRlnaeyecctereiiaicvtvaeeelddd:ssRe202s06-u--l7J9tE-7sL-2-20200000044
Program Namsea:mp=l~eCs:A CL2O0S0~4D15L3A6~8T-- D-PIL2L00A4S1S3E3S7S~6T~T
Date Generated: 26-J~YL-2004
-- Cau pages 7 of Request Page : 7 of 8
: SStitee eIDp .. -
ain co. sir PrPojr ectoyNaj ammseect
WASH CO. SLF
ET --StSap mpll ed Bo y JIM KELLY
SaHmo:p2004l159e74] Receiving Commente: FRIEDRICH
200419974] Receiving Comments:
SCoouetoaieoot commie me3 w Coll Date Coll Time Field No
FRIEDRICH
uUnniisqg3u4essS1ii0teem nIaD7
reip 2Blank 20-JUL-200~ Trip Blank
fpFiie1e1srl3ad6sBielaannk
7
He common ame 9345 31ST ST
Wall Common Name
20641997~
ly.
E
mies onanme cammeTRr
Unit: ORGANXC CHEMXSTRY
Remit Result Sota: Fontive Organic Resica axe inicased oy R15. Note: Positive Organi Results are Indicated by BOL~.
[a ---- 553 PFOS/PFOA in Water ror os PFOS vo pA PFOA ---- peak present; es~ conc 0.6 ppb.
< 0.5 < 1.0
Rheepptt lLeevveell w~aniittss
ons ousen 0.5
ug/L
1.0
ug/L
Asalveis Date
AnalMsis Date
s3-az00a 23-JUL-2004
crop 2070 sample mage 3 of 3
Grou~p 22617~ Sample Page 1 of 1
11995555..00001122
MMNN..330033..00000033..000000007711
MMiinnnneessoottaa DDeeppaarrttmmeenntt OOff HHeeaalltthh
Prelintaacy Repost - Client Copy -
PrograoPrmrooggHrraaammns:::
MaQPPnWrOeRliCm~LiOnSaErDy
Report -
LANDFILL
Client Copy
ASSESSNET
-
Program Neme~ MPCA CLOSED I~%NDFI~L J ASSESSM~T
Ssa~ mplleese:: 220000441199996680 -- 220000401199997766]]
sSiittee2 ID -
Pparrooajjeeccctto.Ntaasmmueex
WASH CO. SLY
-- EEnvviirroonnmmeennttaall LLaabboorraattoorryy Report Of Analytical Results Report DOaDRfcaetUAenGaeRlneyecteriiacvtaeeldd:.Re2-- 2s60u.-l0Jt7Us1L.-22000048
DatSeevGeennseraPtaegde:s 8 of 8 26-J~TLo2004
BReetqeueRsetporPiaegde:s 8 of 8
Date Reported:
sepa Sampled By Frye JIM KELLY
[Sawmop: l20e0419975| Receiving Commenter LorrecuEn
ce ont pn ace colinTeime piel2 so Sample No: 200419975I Receiving Comments: .g011_,Date Coll Time Field No
.LOETSCHER
uunnitqaueesSpcitere iI1D0
20-J~L-2004
Trip :Blank Trip Blank
PFii2o1e0l2l00ads0aslBslananenkk
8
Heli
Well
CCoonm:nmoonn
name
Name
9066
31ST
ST
-
200419976
_
Notes Foritive Grpanic Results axe indicatbRReeeydsmu3iltt0.
553.NotPpr~ePFr:FoOoOrSSsP//oPesFriOctAhiviienn
veces Organic
Water
Results
are
~n~catsdby BOLD.
H<i os0.~
es PFOA peak
pprreessuemnets;
e~nsst
ceoonne
00..33
zpepbb..
< 1.0
RReepptt bLeevveell sUniittss
os wan 0.5
ugiL
noun 1,0
ug/L
AAnmailvyesiiss DDaattee as-z00e 23 ~JUL~2004
[amie Ho: zo0tt997] Receiving comence: -
,c~oql~l!_~p%a~t_e_. cold Time Field ne
Co!! .Time Field No
.~.
Sieve site 12
Unique Site ID
rip Trip
:BBllaannkk
pFi2ie0ll0-adsipsBlalanaennkk 9
Wel comon tame FIELD BI~I~K
Well Common Name
A- o----2--0041--997--6 ---- STE PRR. titi enbsshesiain pees
Unit: ORGANIC CHEMISTRY
Notas Sositivn Oxpantc Ramsits axe indicatedRRbeeysmu3il0ttD.
[FrEorp------ Note: Positive Organic
553 PFOS/P~OA in Water
Results
are
indlcatedbyBOLD.
os
rPFoOnS
I< i0e.5
PFOA
< 1.0
RReepptt lLeevveell Gaits Units
0Y0o~s5o uwwg/nnL
1,0
ug/L
Group 210 sample ge
Group 226170 Sample Page
AAnmaallyvseiiss DDaattee s2-ria00a
23-JUL-20~4
1 ot 1
1 of 1
11995555..00001133
MMNN..330033..00000033..000000007722
ARY
WA .
La
EE PE
oD
V7
4 2)
wnecaer SOUTHWEST QUARTER OF SAMPLING AREA
: a)
|
i Peal
= TRY
Eo T 2 a : 3 0A Xe
SFEGnRESends (Opbp ,
i NN
5
1955.0014
Street No.
Name
Phone Unique No. ~atei W _tr._ On Wtr. Off ,Sampted
Sample Comments
31st Street N. 9018
Stephen Ch~ebeck& Pat Barrett 770-3286
tap W side of house, yd hydrant
9038 .........Wi'lliam & E]len Hughes
c ic]WNTl ROP 1S YE Idi 9046 [oo Jemiememes om wsglwelpe FEEEER 9098
Keith & Susan Weiand .1 '=r~'omas Friedrich
l i 1I l PY11)EE I 9078
Brian & Brooke Hauser
I di sc]I TEPEP tial 9095
Christopher & Lisa Salazar
[oor [reer hlEmle]1| ePOsOpFePPmEO n SEbTbAiEiid 9141
Theodore Sterbenk
1,770-2107 82W01003 770-5160 82W01004 777-0113 :~W01024~ 748-3662 779-8331 82W01005 770-4t77 82W01006
tap N side of house tap E side of house
taps front and back, will bypass soft..sed, filter sample E tap, leave info on VOC/N/bact. Testing
taps W, E, S sides of house
9148
Donald Delander
777-5883 82W01007
tap behind house
9181
Arthur & Gloria Knoblauch
777-6471 82W01008
tap W side of house
9202
[oh m [renee ree te]l 7%El sE PeTsI] Ilia| 9343
Thomas & Micheile Arcand Paul & Charlene Friedrich
779-6542 82W01023 777-2201
tap in back of house (don't use front taP)'
9345
Jim & Nancy Friedrich
777-6424!
several taps
ena 1 1 _T[[TT | Stillwater Blvd.
9517
Douglas & Andrea O'Shea
9521
Harry Besch
9.524
Lee & Molly OIson
747-1393
10240
Common Ground Church
Eolwel I sl |WilTC712T 73 7T ) T1Y | Stillwater Lane
10120
Steven & Linda Kal~evang
EgC orTee s T y jeE re GTymTeTw e5r7 T Sr T 10174
Rober~ & Judith Taverna
748-7984
770-7034 413596 777-8248 82W01021
bypassed softener
1055.0018
1955.0015
Ee fw 10212
James Buege, Sr.
7774228
em hoe odie LLTT KelvinAve. N. [pe gl r fe o| 3490
William & Judy Rogers
3508
Albert & Judith Linder
GC cc Wd 5 3PE i 3509
Robert & Janice Shiltgen
I r lcaior re 7TE in 3533
Donald & Phyllis Paulson
[pre ye use] | 3567
David & Wendy Loos
0 cili 473TF ER 7 3597
Theodore&Edna Buchholtz
770-3448 82W01022 ~1~. I 777-7063 82W01018 770-9603 82W01014 777~187 777-1552 82W01015 770-5197 -8-2WO"tO~
tap behind house Need to remove fitter .... v!
B6bl EW Balan BIOTA far 1117 IAT
oy. Censiden
Sze gar 120 NSD
Iss) Kak
apvoiosd Gor (35 USS
Ho!
es
..
we 1 -
ageSaT t o
ao?
28 Blouwkk - Bogasa l1o01lo01t Kein
1955.0016
I James Kelly, Fwd: Chemistry Lab Program results report ~ i~i ii i~i~ ~ii~
~
~
Page 11
DFa3TFr"toro0ors: mm:::
YYoonnggyyii JJiiaanngg.
1Ke0l,4J&a1m5ePsM Kelly, James
Sublect: Date:
Subje~t:
Fc: Chemistry 711/04 4:15PM
Fwd: Chemistry
LLaabb
PPrrooggrraamm
rreessuulltss
rreeppoorrtt
aim,
Jim,
vHHeoerrsoesiaissmttphhleeePPsFcFOoOnStISaPiFInOPrAraFercepeOporoaAtrmt..oAuAnhltthooouufggPhhnFnoOoAnn:eeoofftthheemm sshhoowweeddrreostuiltaabboovvee oouurrreeppoorrttelovvse,, tthheerrea arroe
three samples contain trace amount of PFOA:
22222000000004441110055668094490779::110:0000../..8446658833841616500ppppppppp10pbbbb((09(F((FFFFiiiiieee::eolllldddddIIIIIDDBDDDB8882Z222WWWWWO0O00111100100202100309,,1,, ffrrSrrrooooo,mmmmm999990300334774858853313331111ssssstttttSSSSSttttt.,.,
JBJiirmmaananandndNdNaBanrnoccoyykFFerdiHeeadcuriisccohhr.))) WBdanianadlnBdErolioekneHaHuaguhsmeesr.))
200416010:0.545 ppb (Field ID 82W01003, from 9038 31 st St, William and Etlan Hughes.)
OOnnee aaddddiittiioonnaall ssaammpplleepposossisbibllyyccoonnttaaiinnss PPFFOOAA t1o0o0,, bbuutttthhee ssppeeccttrruumm iissnnoottccoonnfifirrmnaattiivvee..
200416008: 0:353ppb (FkID BZWOfr1om 080405 341st,Sr,KhandSusan Weland) 200416008: 0.353ppb (Field ID 82W01004, from 9046 31st St, Keith and Susan Weiand.) Yongyi dua Jang Yongyi Julia Jiang Resoarsh Sconist Research Scientist Pubic Health Laboratory Public Health Laboratory Minnesota Department of Hoalth Minnesota Department of Health Phone: 812.676.5570 Phone: 612-676-5579 Fac 6128765514 Fax: 612-676-5514
ccCC::
: Swederborg, Paul
Swedenborg, Paul
--(cgpotbiomybe=ckS"ppobkeotnprea?
esha) th
[de
12 wis ~PFO" ye cS
`
11995555..00001177
MMNN..330033..00000033..0000000076
MMiinnnneessoottaa DDeeppaarrttmmeenntt OOff HHeeaalltthh -- EEnnvviirroonnmmeennttaall LLaabboorraattoorryy
FFiinnaall RReeppoorrt~ -- CCll~ieenntt CCoopPYy -- RReeppoorrtt OOfF AAnnaallyyttiiccaall RReessuullttss
ProgrPaPrrmoogNgreraeam:m:: PavCA CLOSED LANDFILL ASSESSNET
DaDDtaaetceeGeRRneeecczeeaiitvveeeddd::: 222151---J77~UoNnm---222000000444
Program Name: ~PCA CLOSED LANDFILL
DaRtReeeqquuGeeesnstetraPPtaaeggdee::: 25-11JON-oo2ff00&55
samples: Samples: 200015001 200415881 = 200615850] - 200415890I
DDaattee RReeppoorrtteedd:: 2277--JUUmN--22000044
MsSNiiSttNeeOO1ILD
MN~r001
WASEINGTON CPPOrrUooNjjTeeYccttSANNNaaImmTeeARY LANDFILL
WASHZNGTON COUNTY SANITARY LANDFILL
sSaammppileedd BByy ~Jiimm RKeellllyy//GOilmazn~y YTiinnoglliinngg
[[SSaammplpeleNtToo::o202000441155988811 |I RReecceeiivviinngg CCoommmmeennttss:: cbooicmv~mamoonn ggrroouunn~d chhuurrochh,, 1100224400 ssttiillllwvaatteezr
2CC1oo-l!7ll0-DD2aa0ttee08
21-JUN-2004
Trip Blank
Trip Blank
CCoollll10TT2ii0mmee
FPiiesll1dd
No
No
1020
1
Pield Mak
Field Blank
unique site 10
151756 Unique Site 151756
ID
wel) common Name
Well Common Name
200415901
-
CGChuz=h
****************************** SAMPLE RESULTS ******************************
vate: onawvre camesTRy
Unit= ORGANIC C~EMISTRY
Reviewed By FDS on 27-N-08
Reviewed By PDS on 27-JUN-04
Note: Positive Oxganic Results are indicatedRbeysu3l0tID.
Rote: Positive 0rgamla Results are
555533 ePPrFroOosSs//PeFrOoAn iinn wWaatteerr
< os
eon PFOS PFOA
< 10 < 0,5
< 1.0
Rept level Units
01o.0s5 uwwge/nnL
1.0
ug/L
Asalvais Date 22-2004
22-JUN-2004
i[SSaammppllee NNoo::
200415882|
200415882I
RReecceeiivviinngg
CCoommmmeennttss::
33449300 KKEELLVVIINN
2CC1oo-ll7ll0nDp-aa2tt0ee00
_Coll Time Coll10T8i5me
Field No 2 Field No
nuniiqquuee sSiittee 10 amo1022
2!-JUN-2004
!055
2
82W01022
_TT2or0iipp0B3Bl3la0an1nkk FPiieelldd-BBllaannkk
WWeellll CCRooommgmeeronsnNNaammee
200415901
-
auniit~:: OORRGGAANNIICC CRRMTSTRY
RReovviieewwsedd BByy PFDDSS oonn 2277-J-UN0-084
Hote: Rosteive organic Results are indicatedRbeysuDlOtLD.
53
553
eePrrFooOss~,//pPeFoOnA
in
~n
water
Water
< os
sPrFOoSx
<i < 0.5
PFOA
< i.~
Rept Level Units
0oT.so5
uwwge/nnL
1.0
ug/L
Asalvais Date 22-00-2004 22-,_TtJ'~-2004
GGrroouwp 22233663344 SSaemmppll~e Pmaagge~ 11 ooff 11
11995555..00001188
MMNN.330033..00000033..000000007777
Minnesota Department Of Health - Envilromnmental Laboratory
er att So ae Tr oer Final Re~or~ - Cl~ent Copy - Report Of Analytical Results
-- an Program: ~w erm Ee ceesors ern ope e Tav, Progr~ N~: ~ C~ED ~I~ ~ES~T
Date Received: 21-~-200A Date Generated:
Retest Page: 2 of 5
er vores AH ,S~lem: 200415881 - 2004158S0~
Date Reported; 27-~-200~
wren rere any Site ID er l~ISW001
Project Name WASHINGTON ~ ~TARY LANDFZLL
Sampled By JLmKell/Olnm~rYingl~m~
ET Te ---- ISample No: 200415883] Receiving Co~ents: 3508
coun ot nim risa imesso 2 Cell Date I pe 21-JEN-2004
Cell Time
1057
Field No
3
Unique Site
82W01018
rr fe wom Trip Blank Field Blank
Well Common Name
200415901
-
Lin~e~
A ses iv opt npwr woo, in 553 PFOS/PFOA ~n Water 7 Cee es an P~OS = won om PYOA
Reviewed By PDS on 27-JUN-04
Result
Level UnAts
< 0.5 < 1.0
0.5
ug/L
i~0
ug/L
[a2mpl0ev0o: 4158 |Rec8eiv4ing Comments: Isample No: 20041588~] Recelv~ng Commen~s:
33550095 KKEELLVVIINN
woe omni rian Here tanss Cell Date a ye aie 21-~-2004 nies. fer, a. Trip Blank Ta Fer 200415901
Co11 Time
1100
Field No
.
Field Blank
Unique Si~e ID
8~W0~014
Well Common Name
Patino
22-JI~-2004
wie xmascomin pr1iioon1rms
swe
tin
st
eins
on fontvee Reviewed By PDS on
Sw27-JD~-04 Rept Level
wivunits
wms
Cteewone0.5 oamnug/L
1.0
ug/L
stot on
22 -JUN-2004
Group 223634 Sample Page 1 of 1
11995555..00001199
MMNN..330033..00033..0000000078
MMinnesota Department Of Health - Environmental Laboratory
Final
Final
Report
Re~ort
-
-
CClliieanntt
CCooppyy
--
RReeppoorrtt
OOff
AAnnaallyyttiiccaall
RReessuullttss
PrograsPnrroogNgraramanem:: aNvFCA CLOSED LANDFILL ASSESSNET
DaDDtaaetteeGeRRneeeccreeaiitvveeeddd:;: 322i51---JTstTm~H---2a2000000440
empies:o _z00u1m 3ee-1 z00arseso]
DaatRRneetoequuGeemssneeteproarPPttaaeuggdtee:,: 2257-33-~cDmNmoo-a2ff00008458
200415881 - 200415890I
Date Reported: 2?-JUN-2O04
MsSiiOteeNOID ASKINORON CPpOrrUooNjjTeeYccttSANvNaaImsTeeARY LANDFILL Gia FeliySs/aaGmmlppallneeydd TBBiyyngle
~SW001
~J~INGT~ COUNTY SANITARY LANDFILL
Jim Kelly/G4--y Yingling
G~ampaletNmoo:: b220000l44115588e8855]|
RReecceeiivviinngg
Comente:
Comments:
3533 Faavan KELVI~
3533
aCccoeollllmeDvaaanttoees cCoellll11TT0iismmee pFiisetla:d wNoo
UtnhiqiuseeanSsoiisttoeezeID
2TT1Zre-oiiJvppUeNaBBs-ll2saa0onn0skk4 FFii1ee1ll0dd5-BBllaannkk 5
well commen name 82W01026 Well PCaosmimeoonn Name
200415901
-
Pauimon
nt: ORGANIC CHEMISTRY
neviewed oy 108 on 27-000
Reviewed By PDS on 27-JUN-04
Hote: Fosttive Organia Ramee are indicatedRRBeeysmu2il0t~10-
555.
553
PPorFFrooOOonsSSs//PoFrOoAn
in
in
uacer
Water
<i < o0.s5
PFOA
< 1.0
Rept level Units
0iso wwnn 0.5
ug/L
1.0
ug/L
Tampiene: 200413806| Receiving Comente: 3567 RaLvEN
[Sample NO: 2004~5~86 ! Receiving Comments: 35,7 KEL%r~
SCCioelelllmepDaaaottnees_ cCeollllisTmiismmee
FFiieelldd:
ne
No
UonniiqquusesawsSoiiattoeeisID
~TTI2rr-0Jii0Upp6N1BB-5l2l3a00an01nk4k
_pi1e1l3d5 Blank - Field Blank
6
a1 Common ame Well po Common Nam~
82W01015
200415901
-
Lees
Asaveis Date ---- 22-JUN-2004
Dn: ORGNEC CHRGOTRY
Un~:: ORGA~ZC C~EM~STRY
neviewed by sos on 27-5u-08
Reviewed By PDS on 27-JUN-04
Hotes Bonttive Organic Remts are intloasedRRbeeyssu3ll0tt15.
553
553
PsPTrFeFreOoOosSSsn//PeFrOoAn
in
in
ater
Water
o<< no0.s5
PFOA
< 1.0
Rept level waits
0s wn 0~5
ug/L
Yoo wn 1.0
ug/L
Aaivals Date 227m2004
22-JUN-2004
Grow 213634 sample rege 1 of 1
Group 223634 Sample Page 1 of 1
11995555..00002200
MMNN..330033..00000033..000000007799
MMiinnnneessoottaa DDeeppaarrttmmeenntt OOff HHeeaalltthh -- EEnnvviirroonnmmeennttaall LLaabboorraattoorryy
FFiinnaall RRe~porrtt -- CClliieenntt CC~oPp~y -- RReeppoorrtt OOff A~naallyyttiiccaall RReessuullttss
Progran: ov Progran Name: MCA CLOSED LANDFILL ASSESGMET
DDDaaattteeeGeRRneeeccreeaiitvveeeddd::: 222511---JJ~UU-NN--222000000444
DatRReeeqqGuueeenssettraPPtaaeggdee::: 2544-~-oO2ff00455
[semptes: 200413881 = 200615050
Date Svporteds AT-ou-200k
Sa~i~les: 20Q415881 - 20041589QI
Date Reported: 27-J'0~-2004
_sMSiNitGteWe00I1D |
PPrroojjeecctt ~Naammee WASHINGTON COUNTY SANITARY LANDFILL
MNSWO01
~INGT~CO~NT~ SAR~TARY LANDFILL
sSaammppileedBByy JJiimm KKeelll1y/1GGilnmnmy~YY1inn~gllinn~g
Saammppllee NNoo::
2200004411558888'77|t RReecceeiivviinngg CCoommmmeennttss::
3597
359';
KELVIN
KELVIN
2CC-oogllllm-DD2aa0tt0ee0 _ CCoollll11TT4ii0mmee FFiieell7dd Nwoo
Unniiqquuee Ssiittee I10D. svo1016
~l-u'~R'-2004
1140
7
82W01016
Teip Blank Feld Blank
Trip Blank Field Blank
eWellll CCoommmoonn NNaammee
220000441155990811
- -
Bucukoh~oitte=s
eraesessraressaeseesaasareeas SAMPLE RESULTS *++4tsereiseAssisnerasasseies
****************************** SABLE P~ESULTS ******************************
nUniitt:s oORRGaANNIICC CC~HER~OISSTTRRYY
RReevviieewweedd BByy PPDDSS oonn 2277--d5-1~N--0084
Result Note: Posteive Orgaaic Resslts are indicated by BOLD.
5S5533 epPrrFooOssS//PeFrOoAn iinn WWaatteerr srPPFFoOOnSA
<<< 01o,0s5
< 1.0
Rept level Tatts 001..055 wwoorr
ug/L
Amlveis Date 22-quv-2000
22~JU~2004
I[SSaammppllee NWoo:: 220000441155885888-|] RReecceeiivviinngg CCoommmmeennttss:: 33668811 KKEELL%V~IXNN
acCroo-llglmleDpzatoae0t8e CCoollll14Tf7immes FFiieellsddNNoo
UUnniiquseeaSwSoiistt0e2e7ID
21-~0~-2004
1147
8
82W01027
TTrriipp BBllaannkk
FieldBlank
Field Blank
Well Common Nase
Well Common Name
200415901
-
Sesublen
200415901
-
Beaub~en
aUmiie~:s oORRaGAANNIICC CUHam~EMIISSTTRRYY
RReevviieewweedd BByy 9P0D5S oonn 2277--J0L~8N--0044
Result
Note: Positive Organic Results are indicatedRb~ysuOlItD.
555533 bpPrrFooOssS//pPrFoOnA tinn wWaatteerr
< os
EXPFOS PFOA
<<< 011..050
RReep~tt Lleevveell
Units
Units
010.,055 uwwgaa/lrLtn
1.0 ~
ug/L
A~Aaslavlsvliss DDaattee 2222--J0U0N--22000004
Grow 223634
Grou~ 223634
SSeammppllee PPaaggee
11
ooff 1
11995555..00002211
MMNN..330033..00000033..000000008800
MMiinnnneessoottaa DDeepDaarrttmmeenntt OOff HHeeaalltthh -- EEnnvviirroonnmmeennttaall LLaabboorraattoorryy
FFinnaall RReep~oor~tt -- CClliieenntt CCoopp~y -- RReeppoorrtt OOff AAnnaallyyttiiccaall RReessuullttss
PPrrooggrraamm:: o~Ww
DDaattee
RReecceeiivveedd::
21-7Tm-2004
21-J17N-2004
PPrrooggrraamm NNaammee:: MMPCCAA CCLLOOSSEEDD LLAANNDDFFIILLLL ASSESSMET
DDaattee GGeenneerraatteedd:: 2255--J7IURN(--22000044
RReeq~ueesstt PPaaggee:: 55 ooff 53
samples: 220000441155808811 -- 200415890 200&15890I
Sete Spates MEI
Date Reported: 27-~-2004
sMSiiItSteWe0ILDd WASHINOTONPCrPOroUojNjeTeYccttSNANaNamImeTeAR_Y_L_AN_DF_IL_L _ _J_im_Ke_ll_yS/aGSmipnwlmeydpTBliyngelidngBy
)mswool
W~INGT~NCOU~TY SAN~TARYLKNDFILL
[sample No: 200415889| Receiving Comments: 3691 KELvIN
Sample No: 200415889I Receiving Co~ments: 3691 KELVIN
aCCnoo-llollmDeDazatt0ee08 CoCollll1T1T5ii0mmee FFiieell>ddNNoo
_
nUniiqquueeSaSsviiettese 10
21-JUN-2004
1150
9
539248
`TT2rr0ii0pp41BB5ll9a0an1nkk _PFiieellddzBBllaannkk
WeWelleldoCCdooemmrmmooinnchNNsaammea
SE
SEL RESULTS SHS----------------
ate: oRamwIC cREMSTRY
Reviewed By 108 on 27-70-04
Rev4~ewed By PDS on 27-JUN-04
Result
Notes Positive Organi Results are indicated by BOLD.
555533 PpbFrrOooSss//PoFrOoAn iinn wWaatteerr
< os
ePPrFFOoOSnA
<<pap01e.,r50
Rept Level Units
o10.s05 uwwogar/rtLt.
1.0
ug/b
Analvais Date 22-2000 22-OUlq-2004
S[Saammppllee NNoo:: 220000441155889900] i RReecceeiivviinngg CCoommmmeennttss:: 3355511 KELVIN
acCnoo-llollmDeDazatt0ee08 _ CcoolllldiTTsiismmee FFiiee1ll0dd NNoo
UunniiqquueeesSiisttee I1D
21-0UN-2004
Teip Blank
1155
10
Field sank
Wel Common Name 493185
T2r0i0p41B5l5a0n1k
200415901
- Field Blank -
Well Coans~nkon Name
EE. SUELE RESULKTaSskSires --------------
Uantie~:: OoRnGaAmNuiIcC cC~aEmMaIsSTTRRY
Reviewed By 05 on 27-00-04
Reviewed By PDS on 27-JUN-04
Hote: Positive Organi Results are indicatedRRbeeyssuuBllOttLD.
Note: Poslti~e OEganl~ Results ere In~Icated ~ BOLD.
553
553
PobFrrOooSss//PoProOnA
in
in
water
Waer
< os
PsFrOoSa
<<i0.5
PFOA
< 1.0
Rept lLeevveell UUnniittss
001..055 uwwa~ar/rtLi.
1.0
ug/L
AAnmaallvvsallss DDaattee 22-30-2000
22-JUN-200~
GGrroouupp 222233663344 SSaammppllee PPaaggee 11 ooff 11
11995555..00002222
MMNN..330033..00000033..000000008811
MMiinnnneessoottaa DDeeppaarrttmment OOff HHeeaalltthh-- Environmentaall LLaabboorraatory
FFiinnaall ~ Rez por~t -- CClliieenntt CCooppyy -- RReeppoorrtt OOff AAnnaallyyttiiccaall RReessuullttss
Progran: aw
Date Received: 21-m-2004
PPrrooggrraaPnmroNgNarasameme::: ~MQWI.CAA C~LOOSGEEDD LLAA~NDDFFIILLLL A~SSESSESS~ETT
DDaaDttaReeteeqGGueeeRnnseeetcrreaaiPttvaeeegddde:::: 22551--0~8--2o2f0000446
~,~le.. 200415891 - 200,15~0i1
Date Reported: 27-2004
Date Reported: 27-~-2004
wsSitteoeImD
eroject vase
sampiea ny
WASCEOUNITYSNANIGTARTYWNODFINLL| THRELLY/GIENEYINGLING
ISW0Ol
Receiving Contents: AMES BURGE, SR 10212 8 LANE
ISample No: 200415891I Receiving Conm~ents:
ecCogollwaleapDaa0tt0eed cCoollll13TT3ii0mmee FFiieelld1d Nvoo
uniqueeawsoiit0e710
21-JU~-2004
1330
1
TT2rr0ii0pp01BB5ll9aa0nn1kk piel-Blank
vel Comontaze oge.
200415901
oat: onaasre camasTRe
Reviewed By 708 on 21-00-04
Reviewed By PDS on 27-JUN-04
Mota: positive Oxpaato Rassite are indicatedRbeymiP0tID.
553
553
oPevYooOssS//ePrFoOnA
dn
in
water
Water
< us
PrFoOSr
<<10,5
PFOA
< 1.0
Rept Level salts
0o1.s05 wwug/nnL
1.0
ug/L
Analysis Date 2222--JgUmN--22000084
[FTa or 2n000o150s97] Receiving Comment: ROBERT AND JUDITE TAVEREA 10374 8 LANE
No: 200~15892] Receiving Comments:
oCCoorllmlleDDaaattoeer_ CCoollll1TT3iimmee FBiiel2ed Nlo _O __nme Uniqu`es sawSoir~0ei a1ID er>
21-u-0TI-2004
13~4
2
$2W0021
TT2rr0ii0pp01Bp3ll9aa0nn1kk PFiieelldd=BBllaannkk
eWellll TCCaoovmnemrooanns NNaammee
200415901
-
Ta~zna
OUant~est oOnRaGnAunticC Cc~aEm~aIsSTTRRrY
RReevviieewweedd BByy 7PD8S oonn 2277--J0U0N--0044
Notas Positive Organic Ressits are inticatedRRbeeysmuBilIttD.
ssa
553
reProFoOssS//ePr~oAn
to
in
mater
Water
< os
wPoFOnS
<<a0.5
PVOA
< 1.0
Rept Level vats
10~.0s5 uwwg/nnL
1.0
ug/L
Asalvais Date Date 2222--J0U0N--22000084
GGrroouupp 222233663255 Ssaammppllee Pmaaggee 11 ooff 11
11995555..00002233
MMNN..330033..00000033..000000008822
MMin~neessootta Deppaarrttmmeenntt OOf HHeeaalltthh - Envirroonnmmeennttaall Laboorraattoorryy
FFiinnaall RRee~poorr~t ~- CCllliaenntt CCooppyy -- RReeppoorrtt OOfF AAnnaallyyttiiccaall RReessuullttss
ProgrsaeogNraamne:: aNAnCA CLOSED LANDFILL ASSESOET
DDaDtaaetteeGRReeencceeeriiavvteeeddd:: 222115--J7-Uu2Nm--02200000644
samples: 200015851 -- = 200413901
DsaRtnReeeesa~GoeesssnttereaPPtaagepsede::: E22 TooffE6
200415891 - 200&15901i
Date Reported: 27-JON-2004
WSsiiOtteeO1ILD WASCKOPpDrrIooITjjeYecc,ttNSANNNaaIGmmTeeARIYLOANDNFL 7IXKELLYsS/aaGmmDppAllNeeYddYNBnGyyLTNG
~swool
WASRINGTO~ COUNTY SRa~TARYL~RDFILL
~IMKELLY/GI~rfYINGLING
[Sampl to: 200415193 Receiving Coments: STEVE AND LINDA KALLEVANG 10120 5 1a
[Sample No: 20041~89~ Receiving Comments: STEVE ANDLINDAKALLEVANG 10120 ~ ~
SCCoeoltrtl mDpoaattnees
cCoollll33mT4iismmee
FFiieell3dd
wo
No
_
U minmiteeprSsiei~tvee ID
r2eT1Zrs-oiJvppOaNasBs-la2sa0onn0nk4k FPii1eo3ll4ad5iBllaannkk 3
oWelllTaCCtootm~omrooannnsNa~mee 413596
200415901
-
ais ONGC CHEMISTRY Unlb z 0RGAN~C C~EMISTRY
meviewed by ros on 27-0u-0n
Reviewed By PDS on 27-JUN-04
Notes Fosieive organic Results are osicatedRRbeeysmuLilttS.
553.Notreots/Poasricthivien Oart~eanri~ Results ~z~ ~n~icaZe~ ~ ~OLDo
553 PFOS/PFOA in Wa~er
TPFrOoSn
on < 0.5
PFOA
< 1.0
RReepptt lLeevveell ~Unnlittss
io wn 0.~
ug/L
1.0
ug/L
AAnuasllyvsa~iss DDaattee 2a-ez00n 22-JUN-2004
[ample to:
200415134
Receiving Comments:
MWOOLLLLYX
AANNDDLLEEEE
oOLLsBoONN
9524
9524
8B
BVLVDD
Scioetmmepaaoteas colt42T0ime Fiel`d so iSample No: 200415894I Receiving Comments: Coll Date Coll Time Field No
_
unniiqcueeSvsSaiietteee
1
ID
eip Blank 21-J~N-2004 _pi1e4l2d0 Blank 4
Wol1 Common ame 539268
2006a3901 Tr~p Blank
200415901
= Field ~lank -
Wel! Caot~eoonn Name
Olson
nit: OMNIS CHRGSTRY ORGANIC
Reviewed By FOS on 27-004
Revlewe~ By PDS on 27-J-0N-04
Rota: Poniive Organic Results are intiontedRRbeoysru3llt0t .
551
553
sPPrrnFFoeoOOneSSs//PaFnOoAn
in
in
waser
Water
<C< oo0,s5
PFOA
< 1,0
Rept level Units
0tse wwaenn 0.5
ug/L
1.0
ug/L
Aualvais Date
analv~.tE Da~e
22-am2004
22-JUN-2004
GGroouwp 22233663355 SSeammppllee Ptaaggee i1 ooff 11
11995555..00002244
MMNN..330033..00000033..000000008833
MMiinnnneessoottaa DDeeppaarrttmmeenntt OOff HHeeaalltthh -- EEnnvviirroonnmmeennttaall LLaabboorraattoorryy
FFiinnaall Rle~porrtt -- CClliieenntt CCooppyy -- RReeppoorrtt OOff AAnnaallyyttiiccaall RReessuullttss
ProgrPParrmoogNgrraaammme::: K(a~IW A CLOSED LANDFILL ASSESSKET
baDDtaaetteeGReRenececereiaivtveeeddd::: 222151---JJJ~u0InN~---222000000444
Program Name: MPC2& CLO~DI~K~DFILL~ESSMET
DatRReeeqqGuueeenssettraPPtaaeggdee:::
3 of 6 25-JE~-2004 3
[sumion: 200415091 = 200015901]
Date Reported: 27-o0N-2004
Samples= 200415891 - 200415901
Date Reported: 27-.'~N-2004
JSsuiiottWee00ILD |
WASEINGTON
CPPOrrUooNjjTeeYccttSANaNamImeTeARY
EE LANDFILL |
GTM
Sampled By KELLY/GEN YINGLNG
NNSW001
W~I~GTONCO~NTYSAE~TAR LANDFILL
Receiving Coments: DOUGLAS AND ANINEA O'SHEA S517 BLVD
Sample No: 200415895i Receiving Comments: DODGLA~ AND ANDREAO'S~EA 9517 S BLVD
2CCoo-llll2DD0aattee8 CC0o1l1l14TT2ii5mmee FiFieelslddNNoo __
UUnniiqquuseeawSSoii0tt2ee5I1DD
Trip Blank 21-u'~N-2004
1425
5
Field Blank
Wel) compon Name 92W0!025
2T0r0i6p2B5l9a0n1k - Field Blank
Well oCroo=~noenn Name
200415901
-
ate: omanzc cmmasTRY
RRoevviioewweedd BByy PFDOSS oonn 2277-J-UN0-08~
Bote: rosstive Organic Resuits are indicatedRbeymBiotD.
553
553
ePPrProOOsSS//PpFrOOAR
in
~n
Water
Water
< os
ePrFOoSn
<<00.5
PFOA
< 1.0
Reptievel omits
0oo .s5 wn wn
1.0
ug/L
~[aSammppllee NNoo::
200415896
200415896
RReecceeiivviinngg CCoo~mmmeennttss::
EARKY BESCE 9521 8 BLVD
2cCoo-llll2DD0aattee8_ CCoolill1T4T2ii5mmee FFiieelldd NNeo
nUniiqquuseezvSsoii1tt0ee1010
21-JON-2004
14~5
6
8~01010
TT2rr0iip0p8BB3ll0aa1nnkk FFiieelldd-BBllaannkk
WWeellll CCBooammsmmeoonnn NNaammee
200415901
-
Be~ch
Amalvais Date 23-2008 23~JON-2004
_
ne: onawc camezeTRY Unt~ ORGANIC CHEMISTRY
RRoevviioenweedd BByy P7D0S5 oonn 2277--J9U8N--0044
Rotar Posteive Orsantc Results are iasicatedRRbeeyssuuBllOttLD.
555533No~ePBerFr~oOosSSP//oPPiFRiOOA~Niii~nn
OWza~taenri~
Water
Rem~ll~s
aEe
im~iua~e~ ~ BOLD.
< os
ePrFOoSr
PFOA
<1o < 0.5
< 1.0
Rept level Units
o00.s5 awwga/nnL
l.O
ug/L
AAmnaallvv~eiss DDaattee 323--0JU-N2-0200044
Grow 21635 sample page 1 of 1
Group 223635 Sample Page 1 of 1
11995555..00002255
MMNN.330033,.00000033..000000008844
Minnesota Department Of Health - Environmental Laboratory
FF~innaall RRee~poorrtt -- CClliieenntt CCooppyy -- RReeppoorrtt OOff AAnnaallyyttiiccaall RReessuullttss
PrograPsrmroogNgreaam~nan::: Ma~IWwCA CLOSED LANDFILL ASSESSMET
DaDDtaateteeGeRRenececereiaivtveeeddd::: 222151---J7o~mu---222000000444
Pro_~ram Name: MPCA CLOSED LANDFILL
DatReequGeesnteraPtaegde:: 4 of 25-JD~1-2004
Request Page: 4 of 6
sampies: _2a00o415n89a1 =-i220s000te4i15ss900s11|I
DDaattee RReeppoorrtteedd:: 2277--JJ~UNN--22000044
SJSoiiitSteW0e0rL | WASHINGTOpNrCoOUjNeTcYtSAaImTsTARY LANDFILL
~S'~002
UTM KELLYSS/easmGppDllGeeNdd YBsIyyNGLING ~J.,LY/GINNY YINGLING
[SSaammpplleeNNoo:: 220000441155889977 |I RReecceeiivviinngg CCconm~mneennttss:: JJIIMM AANNDDN~ANCCYY FFRRIIEEDDRRIICC~H 99334455 3311S8TT 8STT
2CC1oo-llollm-DD2aatt0ee08_ CCoollll15TT0ii0mmee FFiieel7lddNmoe
UUnniiqquusee2wSs0ii1tt0ee201ID
21-JEN-2004
1500
7
Teip Blank pield Blank
we11 Common Name 82W01020
200625901 Trip Blank
~00415901
- Field Blank
WelolurCcoimomdornioNname
-
~Santlrte: OoRGnANcIC c~aSmTmReYy
RReevviieewweedd Bbyy P1D0S5 oonn 2277--J1U0N--0044
Note: Sosktive organic Rerslts are foticatedRbeysuBlOtLD.
552.
553
oPbrFroOosSs.//PoFrOoAn
in
in
water
Water
< os
reoPFOS
PFOA
< < <
100.5
1.0
Rept level Units
1[0X.0E5 uwge/nL
1.0
ug/L
[FablNeo:280415833| Receiving Comments: PPAAU~LLAAN~DD~CIIIAWAL~ETN~E FFRRIIEEDIR~IRCIE~
Sam2cpC1ool-lleollmNoeDD:aaat0e0t2se004cC1oo5ll8ll9185mTI1ii0RmmeeeceivFFiiineeglld.dComNmooments:
uunniiqquuseeasmSi1it0te0es1ID
21-JON-2004
1510
8
meip Blank Field Blank
Well Comon Name 82W01009
200aass0 Trip Blank
200415901
5 Field Blank -
WelrlerCcosmemdoznioNname
PC1~r~edr~h
5. Asalvais Date
ra-- 23-JUN-2004
9343
9343
3311S6T7
S8T7
Uantiet:~ OoRnGaANnIcC c~aSmeTsRTRYY
RReevviieewweedd BByy PD0S5 oonn 2271--J0UN--0044
Hota: Sositive Oxgania Remults are IndleatedRRbeeysmuBi10t~5.
555533 PPorFroOosSsi/PrFroOnA iinn wWaatteerr
< os
PBFOYS
<< a0.5
PFOA
< 1.0
Rept level Units
001.s05 uwwge/nnL
1.0
ug!L
AAnuaallyvseilss DDaatt~ee 23-2000
23-JUN-2004
Grow 223635 Sumple tage 1 of 1
Group 223635 Sample Page 1 of 1
11995555..00002266
MMNN..330033..00000033..000000008855
MMiinnnneessoottaa DDeeppaarrttmmeenntt OOff HHeeaalltthh -- EEnnvviirroonnmmeennttaall LLaabboorraattoorryy
PFiinnaall RRee~poorrtt -- CClli~eenntt CCOoppyy -- RReeppoorrtt OOff AAnnaallyyttiiccaall RReessuullttss
PPrrooggrraamn:: ~avW
Date Received: 21-70-2004
Date Received:
Progr~m Na/ne: ~ ~D ~X~ ~S~T
les: 200415691 - 200415901
DatRReeeqtuGee~ssettraPvtaaeggdee:::
3
5
ooff
6
Dette segneon: 27s
Date Re~r~ed:
MsSNiiSttWeeO0I11D0|
Project Name
__ swpSalmeplaedsByy
WASHINGTONCOUNTY SANITARYLANDFILL|JT KELLY/GDENY YINGLING
~swooz
J[SSaammppllee NNoo::
220000441155889999|I RReecceeiivviinngg CCoommmmeennttss::
THOKAS AND MICHELLE ARCA 9202 3187 STAD
T~IAS AND ~CHELLE ARCA 9202 318T STND
C2Co1el-lrllmD-Da2at0te0e8 CoCellll15TT0ii5mmee FFiieellgdd NNoo
UUnniiqquuseeawSSoii1tt0ee23IIDD
21-JEST-2004
1505
9
Trip Blank Field Blank
Well Common Name $2W01023
T2r0i0p41B5l9a0n1k - Field Blank
Well ACroommaonna Name
2~0e4e15u9e0s1asnbesesn-ARstsaARSes SAYPLE RESULTS +4TAtArasssasneserssrssserees
vate: onc czmasTRY
Reviewed By 508 on 27-03-04
Reviewed By PDS on 27-JUN-04
Result Notes Positive Organic Resulcs are indicated by BOLD.
553
553
rDPorF0OssS//pPrFOOAA
in
in
Water
Water
rPFoOnS
PFOA
<<<i0o.s5
< 1.0
Rept level Units
Rept L~I U~t|
[i=0.o5 uwwgoa/rrLnt
1.0
ug/L
Amalvels Date 2233--J3U0N--22000084
[Gamble No:
200415900] Receiving Comments:
BBIILLLL
BBOOG~UEE~SBS
10101
10101
KKEELL%V~IN~
[~_~e _N~[ 2004$900 ] Receiving Comments:
2CC-eogllllm-DD2aa0tt0ee0_ CCoellll14Tm4ii5mmee
FFiieell1dd0
No
No
UunniiqquuseeswSSoiirtt0ee1 I1DD
21-JON-200~
1445
10
83W0101
2TT0rei0ip4p1BB5ll3aa0nn1kk FFiieelldd=BBllaannkk
WWeelll) BCCooogmmummeoosnns NNaammee.
2~0e41s5t9s01sassanter- assteastaenntts SAMPLE RESULTS *+s4tstsssssssessesssesinennes
Uantie~:| OoRGm~&c~C c~mSeTsT~RYY
RReevviieewweedd BByy P3D5S oonn 2277--J0U4N--0044
Bote: Positive Orgaste Results are indicatedRRbeeyssuuBllOttLD.
553
553
ePprFRoO0sSs//PRFOORA
in
in
Water
Water
< os
PrFoOnS
<< 01.5
PFOA
< I. 0
R~eptt L~evi el Units I0i0...o5D5 uuwwggaa//rrLLn
Analvais Date 2233--gJUuNi--22000048
GGrroouupp 222233663355 sSaammppllee PPaaggee 11 ooff 1
11995555..00002277
MMNN..330033..00000033..000000008866
MMiinnnneessoottaa DDeeppaarrttmmeenntt OOff HHeeaalltthh -- EEnnvviirroonnmmeennttaall LLaabboorraattoorry~
FFiinnaall RReeppoorrtt -- CClliieenntt CCooppyy -- RReeppoorrtt OOff AAnnaallyyttiiccaall RReessuullttss
ProgrPaerrnoogNgraramamen::: oN~EvWCA CLOSED LANDFILL ASSESMMET
DDDaaatttoeeGeRRneeeccreeaiitvveeeddd:;: 222511---Ju5~m0N---222000000444
Program Name: MPCA CLOSED -- LANDFILL ASSESS~ET
Request Page: Date Generated: Request Page:
6 of 25-J~GN-2004 6 of 6
[samtes23:00004105x809151=- 3200000&2185990011]j
DDaattee RReeppoorrtteedd:: 2277--JJUuNN--22000044
site 1 M)SeIi~SrtsWeWOO0IO1Dl
Project Nene
i.
Supleany
WWAASSHHIINNGGTTOONN CCPOr0UoWj~TeYctSS~ANrNa~ImTTeAARRY LLAANNDDFFIILLLL
UTM KELLY/GIAN YINGLING Sampled By
u-IM KELLY/GINNY YINGLING
Receiving Coments: TRIP BLANK
Sample No: 2004159011Recelving C~ents: TRIP BLA~K
2C1Coo-ll5ll8D-Da2at0tee00
2~-~-20~
rTari0i0ppaaBBsllsa0~nnkk
200~15901
CCoollll TTiimmee FFiieellddNNoo
= un -
Ii
pied sank Field Blank --
wos
svar UUnniiqquuee SSiittee IIDD
Wel common ame TBISW001
Wel7TlertlppCoBBmmlaoannnkkNa11me
UOnaitte:s oORnGoAuNzIeC cCuIm~a8oTTRRYY
Reviewed By 08 on 27-04
Reviewed By PDS on 27-JUN-04
Note: Tonttive Grganic Remsits axe indicatedRbeysuBl0tLD.
553
553
oPrrFooOssS//rPrFOoAn
in
n
water
W~ter
< os
IYPFOS
PFOA
<1 < 0.5
< 1.0
Rept evel Units
os an ~.5
ug/L
1 wan 1.0
ug/L
Asalvais Date 23-0200
23-JUN-2004
Group 223635 sample Page 1 of 1
G~OUp 225635 Semple Page 1 of 1
11995555..00002288
MMNN..330033..00000033..000000008877
MMiinnnneessoottaa DDeeppaarrttmmeenntt OOff HHeeaalltthh -- EEnnvviirroonnmmeennttaall LLaabboorraattoorryy
PFiinnaall RRee~poorrt~ -- CClliieenntt CCooPpYy -- RReeppoorrtt OOff AAnnaallyyttiiccaall RReessuullttss
PrograPPnrrooggNrraaamnme::: oK~wEwCA CLOSED LANDFILL ASSESSMET
DaDDatateteeGeRRneeeccreealitvveee~dd=:: 222252---,J3JuDmN~---222000000444
Program Name: MPCACLOSEDI~I~DFILL~ESS~IET
DatRReeeq~Gueeesns~etraPvtaaegg~ee:::
1 of 5 25-~-2004 1 of 5
,s~a:~mlpelme~s:
22000044116600007 7
=-
2
02006041166001135)
i
~
Date Reported: 27-Jun-2004
~te Reported: 27-~-2004
MsSNiiSttWeeO0I11D| WASCHOPUroNIjTeYcStNANNaIGmTeARTYLAONDFN ILL UTXKELLY ss&aaGmmpDpllNeeadYsI~yNGLING
~SWO01
~[_Saammppllee NNoo:: 220000441166000077 |! RReecceeiivviinngg CCoommmmeennttss: SSorTTEEPPHHEENN CCKELLEEBBBECC~K && PPAATT BBAARKRREETTTT 95001188 3311S6T7 ST
2CC2oo-llgllmepDzaatt0ee08_ CCoollll12mT1ii0mmee FFiieell1dd NNoo
uUnniicqFuuee1S0Si7it7te0e IIDD
_
22-JOR-2004
1210
1
670770
TTrriipp BBllaannkk FFiieelldd BBllaannkk
WWeellll CCoommmmoonn NNaamsee
-
-
Chlebeck
esbesteeesenssstatesantes SAMPLE RESULTS 44+4ttirsssssssssississsnins
ate: onan cumasTRY
RReevviieewweedd BByy $P0D5S oonn 2277--J0U4N--0044
ote: Positive Organi Results are indicatedRRbeeyssuuB1lO~tLD.
555533
ePprWroOosSs//PpFrOonA
in
in
water
Water
< os
sPrFoOSn P~A
<<< 01i..o50
EReep~t Lleevveell
Units
UntZm
o01.s05 uuwgar/rnLt
1.8
ug/L
Amalvais Date
~lvsis D~te
223--0JI-~2-0200004
sample No: 200416008| Receiving Comments: KEITH & SUSAN WEIAND 9046 318T ST
2cC2oo-llllgmDD-aaate0e 0_
22-,.~N-~OO&
TTrriipp BBllaannkk - -
cCoollll13Tm1ii0mmee FPiieelld2d NNoo
1210
2
FFiieelldd BBllaannkk - -
UvnoiiqqusueaemSs0ii1t0te0e8rIoD 82W01004
WWeellll CCoommmmoonn NNaasmee -- Welamd
Ute: omaawIc cumasTRY
Reviewed By EDS on 27-04-04
Reviewed By PDS on 27-JUN04
Notes sosttive Oxgasto Results are insicatedRRbeeyssuuBllOttLD.
553
553
vPpeFr0OosSs//PpFrOONA
in
in
Water
Water
< os
Ey PFOS
PFOA
<<< 110..005
RReep~t lLeevveell ~Unniitt:s
100..055 uwwgaa/rrL
I.D
ug/L
Amalvals Date 2233--qJmUrN--22000040
GGrreouwp 222239771111 SSaammppllee PPaaggee 11 oof 11
11995555..00002299
MMNN..330033..00000033..000000008888
MMii~n-n@essoottFaainDDaeeRppeaaporrrttt.mmee- nnCttlieOOnfft CHHoeepyaal-tRhep-ortEnOfviArnaoinymeiecnaltaRlesuLlatsboratory
coeasPnerooNggerrmaaanm,:
CanAFiCnLaOlBERDepLoarvtO
-
PI
Client Copy
LL Asta
-
Report
Of bADuDntaaaettleoyGtRRoieencccaaeerliiavvteReededd:s::ul222t228s--J-5U02N--02200000804
sapien, asotseosn = vossenss)
Date Generated:
r Rooser mage: Request Page:
25-JUN-2004
H3 aofr5 2 of 5
Samples= 200416007 - 200416015i
Date Reported: 27-JUN-2004
JsSioitcWeeO0I11D0| VASCKProremooIjgeeeyccttSNKNnIaaUGmsTeeARTYLAONDFNTLA|7M KELLY ss&aasmOppmllaeead YBnIyyNGENG
]~fSW001
WAS~INGTO~ COUNTY SANITARY LANDFILL JIM KELLY & GI~NYIN~LING
Sam0isatAo:i6003| Receiving Comenta:
~ample No: 2004160091 Receiving Comments:
BRIAN & BAGORE EAUEER 9078 310% 07
BRIAN & BROOK~ HAUSER 9078 31ST ST
CCoolill DDaatete CCooilll TTiimmee FiFieellddNNoo
Parra 3 22-u'UN-2004
1215
3
resp mark _pseta mank Trip Blank Field Blank
UUnniiqquuee SSiittee I!DD
savoro1s 82~01019 2 common ame Well Common Name
Dm, CROMNIC CHENIFTRY
Unit: ORGANIC CHEMISTRY
peviened by ros on 3-v0d
Reviewed By PDS on 27-JUN-04
Notas Rosttive Gxpun essen ax tasicnteRRyeesmuBiltto.
[r-- os ---- 553 PFOS/PFOA in Water
Rki < os
PPrFOOAA
4
<< 11.00
Rept lewd omits Units
0s wn 11..00
uugg//LL
umoNo:t30e8416080] Receiving Comments:
ISample No: 200416010 ] Receiving Comments:
WWIELLLLZIANMG && ESLLLLEEN~ RKO~GnH~ESS 39003388
ScCooenitlaoDoatoteet cCoolillmTmsiimnee Fmiieslt`da No
UnniiquaseavSsoiiittoee0sID
ip mark 22-JUN-2004 mi1e2l1e5 mask 4
well comon ame 82W01003
Trip Blank Field Blank
Well C~on Name
asaivets Date m0
$31380T% 5BT%
-
-
Eu~hes
DUneits:
oRONIC
ORGANIC
CCHHEEMGIOSTTRRYY
nevieesd by 108 on 37-00
Reviewed By PDS on 27-JUN-04
Hota Positiv guste Tama sre InsionedRRveeyssuRil5tt5.
Roeoptt Lteevveell aise Units
555533fmPPooFFoOOsdrSSs/ePrFoOnA
tn
~n
sates
Water
<<io0.s5
0on.s5 owuwg!nL
PFOA
< 1.0 0 1.0
ug/L
Asslvata ate
Analvsls Date
21-00 23-JUN-2004
Grow 211 mata man 1 ot 3
Group 223711 Sample Page i of 1
11995555..00003300
MMNN..330033..00000033..000000008899
Mi~n-nesota Department Of Health - Environmental Laboratory
PFiinnaall RReeppooErtt -- CCllileenmtt CCooppyy -- RReeppoorrtt OOff AAnnaallyyttiiccaall RReessuullttss
ProgrDarmogNeaamne:: NPA CLOGED LANDFILL ASSESRMET
DaDDtaaetteeGeRRneeeccreeaiitvveeeddd::: 222522---u7-700-n~-3-22000000444
Request Page: Date Generated: Request Page:
3 of 5 25-,.TON-2004 3 of 5
200416007 - 200416015l
Date Reported: 27-T-2004
Date Reported; 27-,.T0~-2004
MSsuiottweile0D1| WASHCsPorrmooiIjjTeeYccSttNANla~ImGmTeeARTY LAONDFNILL | UX KELLY sS&easmGppOlrReeYda TBnyyIRLDNG
isWOOl
~INGT(~ COUNTY ~TRRY LANDFILL
KELLY & oi~r~ I"~t~LIRG
Sample No:
200416011 I RReecceeiivviinngg CCoommmeennttss::
CERISTOPEER
~RISTOPm
&
&
Lin
LIS~
SNAZNR
~hEL~ER
99009355
3311S8T7
8ST7
C2Coaol-lollwDeDazattoeeos_ CoCollll1T3T3ii0mmee FPiieellsddNNoo _U _ niqUu niqusee amSoi1t0S e03IDited
Trip Blank 22-JON-2004 Pie12l50Blank 5
well Common nase 82W01005
Trip -Blank - Field Blank
Well SCoamtmnona Name
Date: onaame camer
Unit ~ ORG~C
Reviewed By. 508 on 7-00-08
Reviewed By PDS on 27-J~q~-04
Motes Positive Orgasic Results are indicatedRbeym2i0tD.
553
553
TrPpFroOonSs//PaFrOonA
1a
in
water
Water
< os
rPoFOnS
<Saol. 5
PFOA
< 1.0
Rest Level vats
0oo.os5 uwwga/nnL
i. ~
ug/L
[ISamFpleaHNoo::m22p000044l1,16600e1122]I
Receiving
Receiving
Comments:
Comments:
TEKAS FREORICE 9098 3167 87
T~(~A~ FR~E~XC~ 9098 31~T ST
frcCeooilll eDpaattree _rcCorollll)nTiimzee FPiiesl0ldaNnoe
nUniicquseeawSsoiirtt0eee7D
22-3~D1;-2004.
1250
6
Trip Blank Field Blank
Well Common Nene 82W0i024
Trip -Blank - ~ield Blank
WellTrcCiosmamroinoNname
-
-
T~T1edri~b
Amalvais Date 23-2000
23-J~N-204
ate: onawnc cammeTRr
Saviowed By 208 on 21-08-08
Reviewed By PDS n 27-JUN-04
Mota Positive Orgaate Rassits are indicatedRRbeeysmu3il0ttID.
rp bros --
< as
sor
<i
RRee~pZt LLeevveell aUniitss
o0.s5 uwwg/nnL
1,0
ug/L
AAnnaallyvsaiiss DDaat~ee 23-a-z000
23-JUN-200~
GGrroouwp 2222377111 SSeammppllee Pmaaggee 11 ooff 11
11995555..00003311
MMNN..330033..00000033..000000009900
MMiinnnneessoottaa DDeeppaarrttmmeenntt OOff HHeeaalltthh -- EEnnvviirroonnmmeennttaall LLaabboorraattoorryy
FPiinnaall RReeppoorrtt -- CClliieenntt CCooPp~y, -- RReeppoorrtt OOFf AAnnaallyyttiiccaall RReessuullttss
ProgrepPnrrooggNrraaammme::: NaQPwvCA CLOSED LANDFILL ASsEsmEr
DaDDtaateteeGReReencceeeriiavvteeeddd::: 222522---Jo7Du0NmM---222000000444
Program -- Name: MPCA CLOSED LANDFILL
DatRReeoquuGeeessntetraPPtaaeggdee:::
4 of 5 25-JDN-2004 4 of 5
[sempten: 2200041600067 =1- z26000000&116060011735]f
DDaattee RReeppoorrtteedd:: 27-70M-2004
JSsIiiOttWeeO01ILD| WASHINGTON CPOPrrUooWjjTeeYccttSANNNaaImmTeeARY LANDFILL TM KELLY S&aGmpIlNedY BTyINGLING
MNSW001
WAS~INGT~ COUNTE SANITARY LANDFILL
[ample No: 200416013 | Receiving Comments: TFHEEOODDOONREE SSTTEERRBBEENNKR g311~411 33115ST7 5S%T
[Sample No: 200416013f Receiving Comments:
2CCao0lo1l1moDpaaa0tte0es CCoellll1T2Tisimmee FFiieell7dd NNoo
UUnniiqquuseeaswS0ii1tt0ee261I0D
22-JDN-2004
1253
7
rip Blank pield Blank
Wel common Name 82W01026
Trip -Blank - Field Blank
Well PCeosmtmaoonn Name
Pauleon
ade: onanute cmazeTRY
Revioed by 08 on 27-31-04
Reviewed By PDS on 2?-JUN-04
Notas Bositive Organic Rasulta are indicatedRheysuRlEtD. Rl~eepptt Leevveell UUnniittls
553 PFOS/PFOA in Water
brosPFOS eroPFOA
<<<i0o.s5
< 1.0
ow0.so5 uwwg/nnL
1.0
ug/L
[~amSpleaMNoo::m22p000044l116600e1144|J
Receiving
Receiving
Comments:
Comments:
DDO(W~AALLDD
D DEL~ ANDR ER
5148
9148
3311S8T7
SSTT
C2oCael-llolmDeDaaattoeeos_ CCoellll1T2T5iismmee FiFieelldodNNoo _
UnniiqquuaeewosSrii0tt0ee7I1D0
22-J~-200~
1255
8
Teip slask Field Blame
Walcommon Name 82W01007
Trip -Blank - Field Blank
WellDCeolna~nntoenxName
Delande~
Anaivais Date
23-JUN-2004
Tate: onan crmasTRY
Reviowod By 108 on 27-04-08
Reviewed By PDS on 27-JUN-04
Notas Bositive Grgunio Results axe indicatedRbeysu3l0t55.
Rept level Units
Re~t Level ~nit$
Aualvals Date
.
5555f33N~toPeerF:oOsSP//ooPsrFioOtnAiviienn
Owra~taenrle
Water
Results
az~
In~i~ate~ h~ BOLD.
< os
os wan
22-2004 23-JLTN-2004
sonPFOS
PFOA
<i < 0.5
< 1.0
Too wn 0,5
ug/L
1.0
ug/L
GGrroouwp 22223377111 Ssaammppllee Pmaaggee 11 ooff 11
11995555..00003322
MMNN..330033..00000033..000000009911
Minnesota Department Of Health - Environmental Laboratory
reer retin oe ort ot ern ie Final Re~rt - Client ~ - Report Of Analytical Results
roeASeycuesorsss, oe e peers onnnt Program: QW
Date,Received: 22-~-2004
Program Name: M~.ACLO~ED LK~DFILL ASSESS~ET
BweYs eilw re ew rmtST yh [8ea~!es, 200416007 - 2004160151
Date Generated: 25-.3"DN-2004 Request Pa~e: 5 of 5
Date Reported: 27-JD~-2004
Sampled By
[sample No: 200416015| Receiving Comments: GLORIA & ARTHUR KNOBLAUCH 9181 31ST ST
mantis san Coll Date
22-u-~I-200~
Trip Blank
Coll Time
1320
Field No
9
Field Blank
-
-
tsLmens Unique Site ID 82W01005
Well Common Na~e
Kno~lauoh
oo Ht TH ORGANIC C~EMXSTRY
asa--s r--v--s ra son 553 .PFOS/PFOA in Water
PFOS
w=PFOA
sore vm Revlewe~ By PDS on 27-JUN-04
nacreieee roneoraines < 0.5 non om < 1.0
0.5
ug/L
1.0
ug/L
nit--e m--e 23-JUN-2004
cree 3 rier Hae 2 Group 223711 Sample Page 1 of 1
11995555..00003333
MMNN..330033..00000033..000000009922
I [MDH ChaofCiustn ody Minnesota Department of Health MDH Chain of Custody
Chemical Laboratory
717Delaware Street S,E.
Minneapolis, Minnesota 55440
i..ab ~ at~/ Potential Hazard: Yes/No!Unknown
(Circle One)
frm regen If Yes: Chemical/Biological/Other
.(Circle One)
oe eT Standard/Civil/Criminal Chain of Custody (Circle One)
Sa'mplcd By (Print)
"~ ~ ~-,~ t~ Sampler Signature [
Site ID
= Colloction
Dale.
mTI= i u~vvvv
Time
(24 Hour
Clock)
MDH Sample Number
(Lab U~ Only)
Matrix
Number of Containers
(, /;7 #l q ~7' :,-
son 2068 MDH lO00 2068
a --_--
_ Address if N~ded
SAMPLER COMMENTS
PlacedacesorsTTbw
TT TTT ISa moveva ee |
T e Tr Tr e T e ee eeeeTee sTeeee WT
SAMPLER COMMENTS:
: RE~EIV[NG COMMENTS:
Fl rm ore LAB TEMP
C
I
17
1 ree
SEAL INTACT: YES I NO
E
ITEM NO. IO Li RELINQUISHED is BY/AFFIALIATION
TIME
E Pi eee -- res bonse pbo Jor ssonss ye e WhiteLabCopy
'
Yellow Client Cop),
DATE
I ACCEPTED BY/AFFIALIATION
Pink Submitter Copy
1955.0034
> DATE
2)
nne Em T moc nI nR eone CE Te LSTo INSTRUCTIONS FOR TILLING OUT ThE MDH Ct.L~[N OF CUSTODY FORM
~ - Idnlify potential haza~ by ci~ling one of the choices (Yes, No, Unknow.1),
.
2 Mes Cloneeofctheclhoicees.
"BS nihma ae oemg T t Ey eT ec aeCR oCrEe S,~iitee~.D --PPrrienttthheesseitee1IDDunummblex~r'_.
:
Botnet eo et Hr rrek Proeram Code( 2 letters) - Budget Code found i~ the I~DH Chemical Laboratory 1 !andbook.
3 Cote ho gn ot el Contact Natoe -Wb,o to oda~ rcsa~ding questions aboat the samples.
C3ut Se B b tomee reen es 0A OVER RHETS MDH XXXXX - Minnesota Dclmrtrne~t of14~dth C of~C n~r, ~ NOT WRI~ OVER OR ~NGE ~IS
~MBER.
I. EB e s tottte ey eit mpi mie 10, Re~ to = Print th~n~ an~ ~ of~ ~ ~ ~ive ~e ~po~ only ff~e~ ~e ~pecial ~g~n~ ~p!eg ~or h~e a LN p~gr~ ~e.
1 StsStemi. 1|. ~IJZI~[.~LV_L~ Samplerfs) pl~s~ print your name 1 aieresem eg 12. Affiliation/Phone.- Prinl,Agency or Firm you ~ collecting these sampls fiar~.
asec ere Sampler's phone number, 1 aes.stp 13. Sampler ~uu~ture - Sampler(s) pleasesign your na~ . Bt ae tm este - 14. ~1~ - l~tifica~ on ~les must ~ ~is i~i~ (humOrs or leers). 1 Sp erties es 15. ~moline Poin~ur~ - W~ or n~ ~d m i~ ~
16. ais Month,dayandyeascollected(example 01/1397).
Bt ts oesoe et it mshc AM i Tim~ - Mili~ ~ (~ ~r 1~) ~ ~ ~ ~ minute the ~mple was ~lec*ed A.M. ~ ~O~I200g 01 ]0 would
1 D HB mmaioe oon t, 18. MDH~m~e Namer (~b ~ mNb ~ ~w~le ia thisaree. I~is is for ~H iab ~ only.
as ere rmepee t9. Matrix ~ Sample type, i...water.soil,air,fish,slmJge,pig manure, etc,
=Sk ayeareas ee 20.
r C " - By bottle typ~ Ibc number of containers submitted t'or ea~ site,
2 eta even orce t ed 2 Ades hock rmanvt oct caoBs spies khbn ad pr 21, T~tql # of C~t~ae~ - F~h s~ ple~ ~ ~ ~ humor of ~ttles gubmi~d (?~)
22. ~- Pl~ pl~ a ~k ~ ~ ~ v~ ~xcd ~a for thos~ samples w~ch have ~ ~hed s~t.(~)
gDSA RL pteee 23. e~ ~ple. P]~ a~; lf~ ~ n~ ~ ~ ~dilional p~tet ihe~ is
pa EE choomrrnesTALES SRLLT ,24. ~pler Commen~ - Pl~ ~ ~is ~ ~ ~di~ my ~sible "HOT SA~LES",~G~UEL
MET~ ~lc ~ w~ ~.
RS in em "252.5. RRasescei.viviinnegCCoommmmeennttss--DDOONNOOTTwwrirtiteeiinn tthkilstsspimac~ee.. ~ ~ BODor f~cal oliform .samples; re ocd temperalm~ rcadlng fi-om s~anpling oo1 r upon delivery ~o MDH Sample Entry area- lhe~ is by the sink in t~pom 502B.
ol
2277..
S~ ealan~ tac.tY ~~-Fe Foorr MMODHHe sussceoonnllyy.. DDoo
motwrikein
aol wrile ia
this ares.
this area.
i
2288.~
LIileemmNNoo..-lInnddiiccaatteewwhhicichhFFeilelddS/iStitceh#yyoounhhaavveessuubbmmiiiaccddttoo
MMDDHHLLab~oorraatto0rryyfefot~aannalaylyssiissbbyy
item
item
number.(7)
number.(~
BiSrn i det r 29? itelinauished By/Affiliation - Sampl~ sigrmaat and company/agency.
=2 Tuae ri enen at At Cen ; 30. Bate - Date sampt n~|inquisbod.
Time sample~ ~elinqulshcd to the MDH Chemical Lab.
32. A.gcente~ Bv/AI'filDJio9 - Cornier delivering ~ ~ to ~H L~ ~i~ h~. AI~ si~ the" Relinquished By/
REESE A~liai0n" line w~ ~e ~1~ ~ ~iv~ ~ ~ ~H Chemi~ L~t~. ~e s~ples will ~ s~ for u~
~i~ ~ ~H ~ by a~i~ C~ ~ ~ ~Cu~0dy C~to~i~.
it sett I~a[~ -Dat~ scruples ~lelivered or gicen to ourier. = mreseep em JJJIL~ - Time samples delivered to MDH Labot'amry or given to the Courier. Pm Rrl e me I W~|~ Cony of form to Cliea* - Whit~ copy of the Chain of Custody with the r~u[~ ~ned to the client.
Yellow C0~vof ~m ~ ~B Lab - Fw ~ ~ ~. ~k Cony ofFo~ ~m~er - ~to~ ~n ~l~e~g ~ s~ple~
11995555..00003355,
MMNN..330033..00000033..000000009944
[MDH ChaofCiustn ody MDH Chain of Custody
Me rts HT Minnesota Department of Health
Chemical Laboratory
Clienl/Agency..['V\ ~ k~ --~
8) e mmo | TO 717Delaware Street S.E,
s a Minneapolis, Minnesota 55440
= mel Site ID
; ~
Potential Hw~trd: Fan Yes/N~qJnknown ac (Circle One)
foe capstone If Yes: ChemicallBiologicallOther_.
(Circle One)
bctc m cor omg Standard/Civil/Criminal Chain of Custody (Cirlc One)
PPrrooggrraammCCooddee (22elevtteerrs) (~ ol. co.,act
yon 1om_2067
YRiencpurometKtenreoiv_iCduSaEiRwIACEN
en
Contact Phone
Sampled By (Print)
| sm eni T +4S 7 E PYE} Sample Source/Point
Affiliation
MDH Sample Number
(Lab Use Only)
Fe Nu tuber of Containers 8
-- Address if Needed
SAMPLER COMMENTS
[Paeceeldf wonvannalyo Toa TT Ts C TITToCs eGrmealsea ven ||
[dass oegesate la
TUTTISeo od Kallenanae |
[sconesinag dager TP A In venF
Mes
endThem PTT SG 0s dodeenColon]
[denenlgTT lageTTT
De
[[housssalqepveszesy PTTTToeeoT TUTTP I LCSofrT dee |
[ocoslnnseSET Tel TUTTI bs ie peed
|
Jee bind TsTTLTT TT TTDg gee =
Zp
z
ncnne SEAL INTACT: YES / NO
ITI~M NO.
P8D we p l m --_r e == are wlmrrapp e pop ree WhiteLab
RELINQUISHED B Y/AFFIALIATION
.... ~ .; '
i " ~:
TIME
I(," :~, ~
~dMw Client C~p~
DATE
ACCEPTED BY/AFFIAL1ATION [ TIME [
A],/_._:3~,(..:/._..-:.,/ I.:./ ;. I
Pink Submitter Copy
DATE
11995555..00003366
==
=
1 BtT SS m -- .
2S CIR hLXaats-hCaircmleonmeofothecthoiceeI s. rO rEsDs IT h R L| t
'
Enmtwmeetmermi-- n et tare
+ B omenovi eers eDeHCxa eee
+FCoar t ietr ree SENTEROSUES
1 Bemiso pt oe tt psi
1F . S aeeteri phnS rie.
113. 11414.
SBS S amt et eeAa a n bert s deeetets en
1 ontetre
16.
.1177.. ie-MatwyTin 2 hourclock)fortheborand woeiesaaplewas colli.AM. 0000-011120w0ou0ldb,e.
: I Mi DS oeI Peist sOa 18.
20,Smet A eredmA ct re 121. SE rp mo rkot te eect
22.
2S 3. mnor en sosD ee eT SameptSeeTven8to
24.
3
ncEboa Ln --a----
CD 225.solar eon DorriT e har. eeserie
27.
r5n29.
Baesstemetnrsi
drevas:
330. Te Te crit Ct
31.
5gt u m a ton i nn r 32, ec MDH Larryby redCh 2Coa Coy
CoE
ptm 34. toa ----satin
fi35.
RT
I
11995555..00003377
MMNN..330033..00000033..000000009966
Al\ rr [MDH ChoafCuistondy Minnesota Department of Health MDH Chain of Custody
Chemical Laboratory
ere SE | sm Le Se LE 717Delaware Street S
Minneapolis, Minnesota 55440
=TR ET wpoommel Polential Hazard: Yes!No/Unknown (Circle One) hrcCmteex, ten) pn If Yes: Cheraical/Biologieal/Other__(ircle One) minty Getecng om PSLE Standard/Civil/Criminal Chain or'Custody (Circle One)
Site ID.
Program Code (2 letters) ~._~j~ Contact Narne-\i, ,-,,
Contact Phone #
Sampled By (print)
es Sampler Signatud
Affiliation
his Taae s ] Phone ar Number of Containers
Moi I100o00_22118877
MDH
[Foo ntenfini \ERMKEN Meany
ires Address if Needed SAMPLER COMMENTS
Field [D
Sample Source/Point
Collection
Tim~ l MDH Sample
Date
(24 Hour I
Number
MM/DD/Y~/y y
Clock) I
(Lab Us~ Only)
[isms aac malafeadoze :
Tog TTT
esCoonndfactatecShite ua]
[ool
[bes
TOTP
=
77 77
[sheng]nate gown[1 eslLUCCA
[cel2cvan [1 Tul TC COPPA
[ocialzensvee [[Tweed TC COCCTTIRRC--
FS EP 2 I 7 A
[iss[asa oti [| hw] [L[TOPPPPAV------------"""""""1]
shiculze Varia [1 Dig] [ULTCOOPP A"
[dot Poe won[| fs! TT TCACCCOO
7
[ooo enceTVfeel TVTTT
|
SAMPLER COMMENTS:
R[ii~.IV[NG COMMENTS:
fer omc wo z
LAB TEMP ......
C
gr ------ |] ---- rp} RELINQUISHED BYIAt~LALIATION
"lIME
ITEM
Eg Pm tw pe NO. I!,
i p en e Tt eer e -- pee White Lab Copy
Yellow Client Copy
SEAL IN~ACT: YES / NO Pink Submitter Copy
DATE
1955.0038
1955.0038
: INSTRUCTIONSFOR BLING OUTTHEMDICID OF CUSTODYFM INSTRUCrlONS FOR FILLING:0UT THE MDH CHAIN OF CUSTODY FORM 1. Danataspn od Sagoo 8 es LD Potenliat Hazard.- Identify potential ha~rd by circling one ot~th choices (Ycs,~No, Unknown) 2 itis Costecirs. 2, " ~ - Circle on'ofthe choices. 3 SACO iol Css TeSrCo ofCats rms 3. St~*a~hlrAI!CiViYOffier/Crimina] Chain t,f Cu~to~ly~C of C) -The %taadard" Chain of Custody is used for routine
Let pr at om samples. The *Civil" and "Criminal' Chain of Custodies ur used for s~mples wl~ich have the potcnlial to be used in court Ca rt nd rod Sd oFCorts cases. Th~ is an additional charge asslg,ted for Civil and Criminal Chain ofCu.~ody samples. + Chats ieClaswoh cv ees ~ - Print the Client/Agency ~ho should rcczivc the result. 5. DocMuma Pt ofc md oe mer. Protect Name/# - Print the project and/or cost co~[e number here. S.e- se mir $it~ ID - Print She site ID m~mb~r. PrCoal m ot od NO hic Leber Terk. Proeram Code~ 2 le~arsl - Budget Code found ia the MDH Chemical Laboratory, Handbook. 7 Cotas Whom comeropda ustos hosesls. 7. C~n{a~t Nnm -Who to contact regarding questions about the samples. Cone Fr Pers mer enon. 8. C~nlact ~Phnn - Phone number oflhe cOntact p~rson. 5 JARS Mim epsHhCofC krDONOTWRITEOVER OR CHANGETIS 5 9. MDH XXXXX - Minnesota Dcpartmcn*.of Hea[th C ofC manbcr. DO NOT WRITE OVER OR CHANGE THIS
NUMBER.
10. Baptism disso tt sive pony srs ec spnmlsml 10. Rtpgrt tO - Print Lhe name and address ofthe client to recdve the report only ift~ese are special arrangement samples and/or re have a LN program code.
1. Smt aeSitor e ume. 11. Samoled by (l~'inlb Sampler(s) please print your name here.
12 ABionTiens i pyr in yo cin en ples 12. Affiliation!Phone ~ Print Agcn~;y ~r Firm you are co|le~:tin~', these ~amples for..
Bases ose Piton - Sampler's phone numbcr~
15. SS ak oSvs i) nuve I3. Sami~ler Sb,nnlttre - Sampler(s) please sign ymw nan~e.
14. Eh ein os mtmcs ers mbes. i 14. Field - Identification on botttcs mu~ maich this identification (numbers or
15. Semantec ors mmr nity i. re 15.
~
r - Words or numbers used m identify the site.
:
16. Dae Met doy nde lc cle 11397, 16. Date - Month, day arid year ollected (example 01/t3/97).
17. Tie Mi Tio 4 dos rod i le scl, 502,01s0he Time - Military Time (24 hour clock) for the hou~ and minute ~he ~ample '~as c~[lected. AIM. - ooooq200 O110wo,ld be
F0201 0wet0 00m P.M. - 1201-2400; 2200 would be 10:(]0 p.m.
8. MDHSame umber 13sPs eDs taiMOHrsly. ; 18. MDH Sam~l Number lLab ~se oaivb Please Do act write in this area. This i~ for MDH lab us~ only. 19, Mi Sei wns stp en. 19. Matrix - Sample type, i.e.,water,soil,air,fish~sludge~pig yaanure, ete~
2200.. NNuummbeberroofrCCoonntataiinneerrss --BByybboorlt[etty-yppetthhee nnuummbbeerrooffccoonnttaaiinneerrssssuubbmmitiit~e:ddffoorrceaacchh siittee..
!
2. LfCotns- ori pi neeo mrofots bmi?) . 21. Total # ofContainers o Fo~ e~w,h site p[e~s place the to~ number of bottles
2 amet coc er nd er ss i dre 22. See Attached - Please placea check mark in the vertical boxed a~ca for ",hose samp!~ which have an attached
23.
TL ph oe each sample. Please note: If thet~ are numerous analytes an additional parameter sheet is rcquestcd.(.Y~)
4 SkeaPen he nt my oso TTSAMPLES HSTURLOL000K rs 24. ~ - Plcas~ us~ this space ~o indic01 ~y possihl~ 'HOT SAMPLES","GAS/FUEL OIL ODOR", or a
METALS sample that was FILTERED.
i Use the second ar~a of sampler comments if needed. 2 Reson Conia -DONOTwientsa. : 25, Receiving, Comments - DO NOT write in lhls space. BE er a ST 26. Lab Tcmn - BOD or fecal coliform san~p]esi record tempcralur r~ading from sampling ~oo!cr upon delivery ~ MDH
Sample Ena~, area- thermometer is by the sink in room 5028.
1 SolaYoda ForMD oy.Dot rie har. Seal inlact Ye~oz--For MDH use only. Do net write in this area~ 28. Lm cn St yon ave ined MNLie or sis in er) ; 28. Item No.- Indicate which Field/Site# you have submitted to MDFI Laboratory fo~ analysis by item 2. Bela Alton Solrinte od cmp. 29. Rdina~ish~d Bv/Affilialion - Sampler signaturo and company/agency. 30. Dat Desled 30. Date - Date sample relinquished. 31. Tin Tie seis ei MOHChd en Ls 31. Time -Time samples relinquished to the MDH Chemical Lab~
32, Accemed Bv/Affilial~oa - Courier ~eiivering your samples to MDH Laboratory sign here. Also sign ~e" Relinquished By/
se sos I HilLornTesapsle res ro" Affiliation" line when th,~ samples are dilvered m the MDH Chemi~ Laboca~o~. The sampl~ will be slgne~ for upon
ET me or pa Ch CoootsCondi receipt 01 MDH Labor01or~ by a deslgnat~d Chcm Lab Chain of Custody Cuslodi~.
3. It Puestwin comer, 33. Date -Date samples de|ivcre~ or given Io courier.
34. Tin Tin sols NDI Ley ent oe. 34. Time - T~e samples delivered to MDH Laboratory or giwn t6 the courier.
35 MeCom tfrntaCha Wie py te ifCo ye ss pact ec. i ' 35. White Cony ofform to Client - White c~l~y ofthe Chain of Custod~ with the rcsafts r~port~ to the
Yellow Cony of foam tcLMDIILab - [:or MDH Lab us~.
' ..........
A os vei sic rt as Pink Cony of Form to Samnlrr - Given to the person delivering the sample.
11995555..00003399
MMNN..330033..00000033..000000009988
hm31st Street N.
[em Nam.~_e_e
Sample Comment~
9018 @'038 9O46
Stephen Chlebeck & Pat Barrett 77 3286 82woloE
~ten Hughes
i Keith & Susan Weiand
Thomas Fns~fnch
770-210~"~"~ 770-5160 777-0113
~
ed 82W01004
~
OO
tap W side of house, yd hydrant
tap N side of house
cc tap E side of house
Brian & Brooke Hauser
748-3662 requested
taps front and back, wilt bypass soft., seal. filter
9095
Christopher & Lisa Salazar
779-0331 82W01005
sample E tap, leave info on VOCINfbact. Testing
Theodore Sterbenk
77o- 77 82woio
taps W, E, S sides of house
Donald Delander
777o588~--~ ~
9t81
I neOY il iilall 9202
frm rt 9343
ee rm 9345
Arthur & Gloria Knob~auch Thomas & Michelle Aroand ~rlene Friedrich ~y Friedrich
777-6471 82W010-'~'~" 779-6542 82W01023 777-2201 82W01009 777-6424 82W01020
f | m | St!llwater Blvd.
9517
~ndrea O'Shea
748-1182
tap behind house
tap W side of house
To 3c | tap in back of house (don't use front tap) wmmm--m--"-- several taps [7
9521
[ ee 9524
Harry Besch ~ Oison Common Ground Church
5 e |e T [reT ] I Stlllwater Lane TT 10120
~da Kallevang
EE 10174
Robert & Judith Tavema
777-1534 82W01010 747-1393 539268 748-7984 151756
770-7034 413596 777-8248 82W01021
{ _1955.0040
bypassed softener
10212
,James Buege, Sr.
777-6228 82W0t 0 !: 4
[fComo p | p Kelvin Ave. N.
3490
c idh HI 3508 [pe pw eee | 3509 [pew wee 3533 [prf eaens e 3567 [ [e fe e ee 3597
William & Judy Rogers Albert & Judith Linder Robert & Janice Shiltgen Donald & Phyllis Pauison David & Wendy Loos Theodore & Edna Buchholtz
770-3448 82W01022 777-7063 82W0t018 770-9603 82W0t014 777-2187 777-1552 82W01015 770-5197 82W01016
lap behind house Need io remove filter ....
88z Jossonst &
8
1955.0041
q ommnesgne Sex SOUTHEAST QUARTER OF SAMPLING AREA
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1955.0042
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NORTHWEST QUARTER OF
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1955.0043
