Field ID Number

New Jersey Department of Health

Environmental and Chemical Laboratory Services

PO Box 361, Trenton, NJ 08625-0361

Phone: 609-530-2820

RADIOANALYTICAL SERVICES SAMPLE SUBMITTAL	Lab Sample Number

(For Lab Use Only)
(See Instructions)

AGENCY INFORMATION
Submitting Agency

Send the Results To (Full Name)

Project Name

Street Address

Phone

Project Code

City, State, Zip Code

Fax

Memo Number

Agency No.

Email

Final Report Option?

Yes No If Yes:

Tier 1 Tier 2	Electronic Report Option?

Yes No If Yes:

EDD E-2
SAMPLE INFORMATION
Sample Point/Station ID Number/Water Facility ID

Collection Interval (YY/MM/DD)	Time (24h)

Start:	____ / ____ / ____	_______

Stop:	____ / ____ / ____	_______	Sample Type

Water-POE	Soil/Sediment

Water-Raw	Wipe/Filter

Water-Waste	Vegetation

Water-Distribution	Meat

Other: ________
Sampling Site/Facility/Supply/Location/Sampling Point ID

Type of Sampling Event

Compliance	Regular

New Well Test	Other: ________
Sampling Point Street Address

Sample Retention - Retain?

No Yes - Duration ________
System Name

PWSID

Container Description	# of

1 Gallon Cubitainer	_____

2 Gallon Jug	_____

Other: _____________	_____

State Container? Yes No
Facility Name

Trip Blank # (if applicable)

Municipality/County

Sample Collector (Full Name)

FIELD INFORMATION
FOR LAB USE ONLY	Water Temp °C

Sample Depth Ft.

Preserved in:	Pre-acidified Container

Sample Receiving

Field Lab

Date: __ __ / __ __ / __ __

Time: __ __ __ __
Background Emission Rate ((R/hr)

Sample Emission Rate ((R/hr)

Sample pH (Field)

Turbidity (NTU)

Comments

ANALYSIS REQUESTS
Turnaround Time (TAT)

Routine Priority Emergency	Radium by Gamma Method

Total Sus. Dis.

Radium-224 (SM 7500-RA E)

Radium-226 (ECLS-R-RA226/RA228)

Radium-228 (ECLS-R-RA226/RA228)

Ra-228, Radiochemical (NJ Method)

Unsupported Lead-212 (NJ Method)

Uranium

Isotopic Uranium (EPA 00-07)

Total Uranium by ICP/MS (EPA 200.8)

Radon-222 (EPA 913.0)

Tritium (EPA 906.0)	Strontium (ECLS-R-SR89/90)

Strontium-89 and -90

Strontium-90

Polonium-210 (FERN-RAD. 0002.00)

Gamma Spectroscopy (EPA 901.1)

(Specify radionuclides):

K-40	Co-60.	Zn-65

I-131	Ba-133	Cs-134

Cs-137	Ra-226	Ra-228

U-238

Other:	____________________

____________________
Gross Alpha

Evaporation –48 Hour (ECLS-R-GA)

Evaporation (EPA 900.0)

Total Sus. Dis.

Coprecipitation (ECLS-R-GA-CO)

Gross Beta

Evaporation (EPA 900.0)

Total Sus. Dis.
Relinquished By	Received By	Date	Time	Reason for Change of Custody
Name (Print):

Name (Print):

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:

Signature:

RAD-4

FEB 16

RAD-4, Radioanalytical Services Sample Submittal

RAD-4, radiation, radioanalytical services, submittal, chemistry,

EWHITE

2015-07-08

NJDHSS