Field ID Number	New Jersey Department of Health

Environmental and Chemical Laboratory Services

PO Box 361, Trenton, NJ 08625-0361

Phone: 609-530-2820

ORGANIC AND INORGANIC CHEMISTRY SAMPLE SUBMITTAL	Lab Sample Number

(For Lab Use Only)
(See Instructions)

AGENCY INFORMATION
Submitting Agency

Send Results To

Agency No.

Project Name

Street Address

Final Report Option

Tier 1 Tier 2	Would you like copies of the internal chain of custody forms sent with your report?

Yes No	Project Code

Electronic Report Option

EDD E-2
Memo Number

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

Ground Water	Sewage:

Private Well	Raw Effluent

Septic	Industrial:

Ocean/Saline	Raw Effluent

Sediment

Potable:

Groundwater Rule	At Source

Source	Flushed

Confirmation	1st Draw

Raw	Lead Source Line

Finished	Surface H2O Intake

Private Well	Distribution System

Fraction:	Total Dissolved

Other:	________

Priority:	Routine Priority Emergency
Sampling Site/Facility/Supply/Location/Sampling Point ID

Coll. Time (24h) Start	Coll. Time (24h) End

__ __ __ __	__ __ __ __
Waterbody Name

Sample Retention

Retain? No Yes Duration ________
Municipality/County

Type of Sampling Event

Regular Compliance Repeat

Non-Regulatory Other
Sampling Point Street Address

If Repeat or GWR, List Original Lab Sample No.

Sample Collector

PWSID

Trip #

FIELD INFORMATION
Air Temp °C

Water Temp °C

Stream Flow-CFS

Weather Conditions

Sample pH (Field)

Gage Height-Ft.

Preserved in: Field Lab

Date: __ __ / __ __ / __ __

Time: __ __ __ __	DO (mg/l)

Spec.Cond. (µS/CM)

DO% Sat

Salinity (ppm)

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
Cu	Copper	U	Uranium	Fluoride
Organics (Non-Potable Water)
Fe	Iron	V	Vanadium	Mercury	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

CHEM-44, Organic and Inorganic Chemistry Sample Submittal

CHEM-44, organic, inorganic, chemistry, sample submittal, water

EWHITE

2015-07-08

NJDOH