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RENCANA PENGAMBILAN CONTOH AIR DAN AIR LIMBAH

1. Tujuan Pengambilan Contoh

a. Pengumpulan data rona awal lingkungan b. Pemantauan lingkungan c. Pengawasan / penegakkan hukum lingkungan d. Penelitian di bidang lingkungan

2. Data Administrasi Pengambil Contoh

a. Nama Petugas Pengambil : 1. ................................................................................ 2 ................................................................................. 3 ................................................................................. 4 ................................................................................. 5 .................................................................................

b. Surat Tugas / Pengantar No : ........................................... / ............................................................ Tanggal : ........................................... / ............................................................

c. Dokumentasi 1) Form PeminjamanPeralatan 2) Form Lapangan 3) Form Rekaman Data Pengambilan Contoh

3. Prosedur Pengambil Contoh

a. Frekuensi Pengambilan : ...................................................................................... b. Tanggal : ...................................................................................... c. Waktu Pengambilan : ...................................................................................... d. Lokasi Pengambilan : ...................................................................................... e. Jenis Kegiatan (Customer) : ...................................................................................... f. Titik Pengambilan : ......................................................................................

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g. Acuan Pengambilan : ......................................................................................

h. Teknik Pengambilan : - Sesaat - Gabungan Waktu - Gabungan Tempat - Gabungan Kedalaman - Terpadu

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4. Wadah Contoh yang diperlukan

No PeruntukanWadah Polyethilen Gelas / Kaca

Ukuran (ml) Jumlah (buah) Ukuran (ml) Jumlah (buah)

1. Contoh

2. Blanko a. Peralatan b. Wadah c. Penyaringan d. Lapangan e. Perjalanan f. Duplikat Sampel g. Split sampel

Pengawet yang digunakan : H2SO4 / HNO3

5. PengamatanContoh a. Identifikasi / Pengkodean : ....................................................................................

b. Penyegelan Wadah Contoh : Segel / Tidak disegel

c. Tindakan pencegahan selama transfortasi kelaboratorium ;

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d. Tindakan pencegahan selama transfortasi kelaboratorium bila ada ketidaksesuaian ; ............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................

e. Penyimpanan Contoh Uji dilaboratorium ; ............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................

6. Transportasi yang digunakan .................................................................................................................................................... ....................................................................................................................................................

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7. Bidang Pengujian, Jumlah dan Perlakuan Contoh

No Jenis contoh Parameter Pengujian Jumlah Contoh

Volume contoh (ml)

Wadah (P/G)

Pengawat

1.

Air Tanah a. Sumur Pantau

b. Sumur Penduduk

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Air Permukaan a. Sungai

b. Rawa

c. Danau

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3.

Air limbah a. Inlet b. Outlet c. Drainase d. Land Aplication e. Air terproduksi f. KPL / Tambang

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Palembang, 20. Petugas Pengambil Contoh ( )