NCG030240_DMR_20211004

Deere-Hitachi Construction Machinery Corp.
JOHN DEERE HITACHI P.O. Box 1187
1000 Deere-Hitachi Road (27284)
Kernersville, NC 27285-1187
Phone: [phone] :[WicterrqN of
N CC O30211 0 N c.Cxo3o��la Environmental Quality
Received
OCT Oil 2021
TRANSMITTAL LETTER
Winston !:'m
RJ:';ional Office.
TO: Joel Freeman Date: September 8, 2021
Winston-Salem/Forsyth County
Utility Commission If enclosures are not as noted,
Mason Meads Complex Please inform me immediately.
2799 Griffith Road
Winston-Salem, NC 27103 Certified Mail:
[e-mail] 7020 2450 0000 0840 8851
If checked below, please:
( X )Acknowledge receipt.
( ) Return enclosures to me.
WE TRANSMIT:
(XXX) herewith ( ) in accordance with your request for drawings
FOR YOUR:
( ) approval ( X ) information ( X ) review &comment ( X ) record
( X ) use ( ) other
THE FOLLOWING"
( ) drawings ( ) shop drawing prints ( X ) samples ( ) change order
( ) correspondence
Copies Date Description
1 09/08/21 Pace Analytical Chain of Custody Project#925559908
with lab analysis Discharge Pipe 01
1 10/01/21 Data Entry—Pipe 01, Pipe 02 "No Flow"
1 10/01/21 D-H September 2021 Self-Monitoring Report
1 10/01/21 D-H Const Mach Corp_001
1 10/01/21 D-H Const Mach Corp_002
p I IA i % ` CV`mil
Jonathan Chase
Pf ident& CEO
Deere-Hitachi Construction Machinery Corporation
Office: [phone]

Winston-Salem • Forsyth County
City/County Utilities
Water•Sewer• Solid Waste Disposal
Industrial Waste Control Section
Self-Monitoring Compliance Certification Form
Industry Name: Deere-Hitachi Construction Machinery Corporation
Permit#: 2014
Sample Date(s): 09/08/2021
Monitoring Event Type(s):
(Check all that apply)
1/ Self-Monitoring Other(use box below)
[]Flow Monitoring
[ ]Compliance Monitoring
(As required by WS IWC)
The industrial user listed above El is in compliance l l is not in compliance
with all applicable effluent limitations contained in the above referenced permit for the dates in question.
(If the facility is not in compliance, please describe the violation(s)in the space provided below.)
Violation(s):
The Winston-Salem Industrial Waste Control Office was notified of the violation(s)detailed above
on @ , via
(Please be reminded that the City of Winston-Salem Industrial User Permits require the permittee to notify
Winston-Salem Industrial Waste Control of any violation within 24 hours of the permittee becoming aware
of the violation.)
Jonathan Chase (print name), certify under penalty of law that this document and
all attachments were prepared under my direction or supervision in accordance with a system designed to
assure that qualified personnel properly gather and evaluate the information submitted. Based upon my
inquiry of the person or person who manage the system, or those persons directly responsible for
gathering the information, the information is,to the best of my knowledge and belief,true, accurate and
complete. I am aware that there are significant penalties for submitting false information, including the
possibility of fines and/or imprisonment for knowing violations.
&re- 10/01/2021
Signature and Title of Authorized Representative Date Signed
This forrfi shall be submitted with all self-monitoring data, including results from the laboratory, as well as
any monthly flow report that indicates a violation of either the daily maximum or monthly average flow
limit.
Revised 11/21/2017

,-- CHAIN-OF-CUSTODY Analytical Request Document LAB USE ONLY-Affix Wo' `-' }�rfi�tr
Pace Analytical• WO : 92559908
Chain-of-Custody a LEGAL DOCUMENT-Complete all reinvent fields _, f mill ill
multi
,Company:Deere-Hitachi Construction Machinery Corp Billing Information:Deere-Hitachi Construction Machinery Corp ALL SHAI
Box 1187
Address:1000 Deere-Hitachi Rd. P.O.IKernersville,NC 27285 Container Preservative 925559908
Kernersville,NC 27284 . I- I I
Report To:Debbie Randleman [e-mail] Email To:[e-mail] �, —__l_____.._-...._-}_ _ I„- .. _-.I _ „ 1
[e-mail] ••Preservative Types:(I)nitric acid,(2)sulfuric acid,(3)hydrochloric acid,{4)sodium hydroxide,(S)zinc acetate,
Copy To:Luke Martin Site Collection Info/Address:1000 Deere-Hitachi Rd. (6)methanol,(7)sodium bizulfato,181 sodium thiosuilate.(9)hexane,IA)ascorbic acid,(B)ammonium sulfate, •
Ile)ammonium
[e-mail] - hydroxide,(D)TSP,(U)Unpreserved(0)Other, _ `___
Analyses Ilab Profile/Line
Customer Project Name/Number: 'State: County/City Time Zone Collected: i • - -- ----Si t c'h••.�i.•-r:
--- - -- - --- I Site/Facility ID tr: Compliance Monitoring? i� I I l,-u r t u :[son-t u •s Pt,:cut : LA
,Phone:Olsisae ausnexrat44 1
.Email randlemand dhcmc.com I x] Yes I I No ``i t ;r - <r a ire Pre:a r,t • I: NA
CT° i Ot j i ] N, a in-, . N NP.
Z ! I rnu,•eL bottles DIN NA
;Collected By(print):Aaron Paschal Purchase Order It -: DW PWS ID II: I = i :u t t r r.1 eut Volume N H
Quote II. DW Location Code: i w sampl ee deceived on Ice Y N _
!Collected By(signature): Turnaround Date Required:No later than 10 days Immediately Packed on Ice: a von - Ileadsoacr, Accept al:1 c Y II
f� C U6DA Regulated Soils Y H .
(• from receipt of lab I ]Yes I I No 17 samples in Holding Time CD N NA
:Sample Disposal: Rush: Field Filtered(if applicable): = Residual Chlorine Present Y N 427
IX]Disposeasappropriate I )Return I I Same Day I ]Next Day I ]Yes I ]NO CI Strips:
I I Archive: I 12 Day( )3 Day( ]4 Day ( ]s Day 6 Sample pH Accgp Ctr�g1 a /t -� N NA
l ]Hold: pH Strips: 9..1.JI I-]kr:N
(Expedite Charges Apply) Analysis: ,, sul Tide Present Y 14 NA
•Matrix Codes(Insert in Matrix box below):Drinking Water(DW),Ground Water(GW),Wastewater(WW), Lead Acetate St rips:
Product(P),Soil/Solid(SL),Oil(OL],Wipe(WP),Air(AR),Tissue(TS),Bioassay(B),Vapor(V),Other(OT) 0
LAB USE ONLY:
Comp/ Collected(or Composite Res R of a" Lab Sample 11 / Comments:
Customer Sample ID Matrix• Grab Start) Composite End Cl Ctns O
Date Time Date Time N
'Discharge Pipe 01 WW Comp 9/8/2021 10:36AM 9/8/2021 10:41:00AM 1 1 METALS: Cr,Cu,Ni,Zn
Hand
pH:8.43 _
I--
J
I -
-
Customer Remarks/Special Conditions/Possible Hazards: Type of Ice Used: Wet Blue Dry None SHORT HOLDS PRESENT(<72 hours): Y N N/A LAB Sample Temperature Info:
PackingMaterial Used: Lab Tracking II: Temp blank Aecciv Y N NA
8 Therm MP: 02,1 W 1--�
Cooler 1 Terrip Upon Recespt Oral-
Samples received via: Cooler I Therm Corr. Factor: oC
Radchem sample(s)screened(<500 cpm: Y N NA cooler 1 corrected Temp: ,)•.TC
FEDEX UPS Client Courier Pace Courier comments:
ell q 'shed 8 Co�3a,�ny:(rSignature) Datyq/Time: Re 'ved by/Com•an . Signature Dat• Im/:] Li
I,o MT1L LAB USE ONLY
l Relinquished by/Company:(Signature) Date/Time: d• 'om'ny:( ignature)•r Di-/TI e: Acctnum: Trip Blank Received: Y N NA
ea i I Template: HaMe0H TSP Other
Prelogin:
�N Relinquished by/Company:(Signature) !Date/Time: (Received by/Company:(Signature) Dateffime: PM: Non Conformance(s): Page:
N1 i PB: YES / NO Hof:_

Pace Analytical Services,LLC
aceAnalytical® 1377 South Park Drive
Kemersville,NC 27284
www.pacelabs.cem [phone]
Page 1 of 1
Laboratory Report
Debbie Randleman Report Date: 09/17/2021
Deere-Hitachi Construction Machinery Corp. Date Received: 09/08/2021
Project: Deere Hitachi
Pace Project No.:92559908
Sample: Discharge Pipe 001 Lab ID: 92559908001 Collected: 09/08/21 10:41 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
EPA 200.7 Rev 4.4 1994 Chromium 0.049 mg/L 0.0050 09/16/21 14:02
EPA 200.7 Rev 4.4 1994 Copper ND mg/L 0.0050 09/16/21 14:02
EPA 200.7 Rev 4.4 1994 Nickel 0.0062 mg/L 0.0050 09/16/21 14:02
EPA 200.7 Rev 4.4 1994 Zinc ND mg/L 0.010 09/16/21 14:02
Reviewed by: calq4zottiatatj
Stephanie Knott
704-977-0981
[e-mail]
Pace Analytical Services Asheville
2225 Riverside Drive,Asheville,NC 28804 North Carolina Wastewater Certification#:40
Florida/NELAP Certification#:E87648 South Carolina Certification#:99030001
North Carolina Drinking Water Certification#:37712 VirginiaNELAP Certification#:460222
Page 1 of 2

Data Entry IU Name Deere-Hitachi Construction Machinery Corp
Monitoring Location 002
Discharge Month September
Discharge Year 2021
Cadmium, Chromium Copper, Lead, Nickel, Total Cyanide,
pH Total ,Total Total Total Total Silver,Total Zinc,Total Toxic Total Meter Flow
September pH Units mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mg/L mgd
1 NA
2 NA
3 NA
4 NA
5 NA
6 NA
7 NA
8 NA
9 NA
10 NA
11 NA
12 NA
13 NA
14 NA
15 NA
16 NA
17 NA
18 NA
19 NA
20 NA
21 NA
22 NA
23 NA
24 NA
25 NA
26 NA
27 NA
28 NA
29 NA
30 NA
31 NA

Data Entry IU Name Deere-Hitachi Construction Machinery Corp
Monitoring Location 001 •
Discharge Month September
Discharge Year 2021
Cadmium, Chromium Copper, Lead, Nickel, Total Cyanide,
pH Total ,Total Total Total Total Silver,Total Zinc,Total Toxic Total Meter Flow
September pH Units mg/L mg/L mg/L mg/L mglL mg/L mg/L mg/L mg/L mg/L mgd
1 0.0018
2 0.0031
3 0.0013
4 NA
5 NA
6 NA
7 NA
8 8.43 0.049 ND 0.0062 ND 0.0038
9 NA
10 0.0033
11 NA
12 NA
13 NA
14 0.0044
15 NA
16 0.0034
17 NA
18 NA
19 NA
20 0.0026
21 NA
22 0.0049
23 NA
24 0.0034
25 NA
26 NA
27 NA
28 0.0026
29 NA
30 0.0018
31 NA