NCG140005_MONITORING INFO_20160311

bTORMWATER DIVISION CODING SHEET
RESCISSIONS .
PERMIT NO.
DOC TYPE
❑COMPLETE FILE -HISTORICAL
DATE OF
RESCISSION
❑ �f �., OL
YYYYMMDD

STORMWATER DISCHARGE OUTFALL (SDO) - Semi -Annual MONITORING FORM
..= GENERAL PERMIT NO. NCG1:40000
11u
CERTIFICATE OF COVERAGE NO. NCG14 0 0 0 5
FACILITY NAME:��'� � r� Cct-,r 1
PERSON COLLECTING SAMPLES a LQ
CERTIFIED LABORATORY �L 'i�_ Lab #
Lab ft
OPTIONAL INFO:
Part A: Stormwater Monitoring Requirements
SAMPLE COLLECTION YEAR: A(D(:::� _oQ N
SAMPLING PERIOD-f ff July -December ❑ January -June
COUNTY `LJi tt _
PHONE NO. (,Z .
ADD TO LISTSERVE? []YES ENO EMAIL:
DISCHARGING TO CLASS: ❑SA ❑HQW ❑PNA ❑Trout
Other
,
I;�,,.,t=F.�-:s•:�,. : �K,,-S
A5
i_-
i 1 T
1 f
6 i r a.i•r '. t,.;d.-
.�-;.
1-�:.. .,,.D:�aCtoer llSeac_mtept,! ,l,,:et:,;<r,:ir.G�,•
?,.. �`: - :11
1 nv+�?i'1Tr
71'2 -,.
NO FLOW)c #_.a.�a
,Iw-.x-
:P
:r,,�f �`t,i:`,.�i::a�y..p`Hx._•:'�::.fi.-- A�:,•••.,.5}�.�r� _
...Ursits4l',.
7 z,..r'
[, r a
i.• r,i.:::�,i-" i '2 :
.<,r;_.,�},.].y�.:.am�,:._,;:�v�- -�i.. t T- S-«sS ..�,�'at.;-E ,r .t ;.x�.
:
4s:' .ix, ..1.-,,....
.> -
CY .. T:i:.. : i.:7: '.I-!.
.,E,t of :.rf: =s=31':^
P.M.,
Duration :
:,i f
..r�.�f_..E
1{minutes
.�:
cl .1,..1:i_ i
...i x 7w
:=Y.-. �.?:: Y..
otax
:.:,^:7:;: cr}..�,^r��y :cfa*,�s^
i`".
� ,,,Rainfall...:.-�
r i3 .5%
":.� �- .,�;IVlonita�in
1iit{1e
,.:Y..,. c.«-,A- ii_.Z:�
:.i ulk:::1:4:v.F:: ^i
3�i:-
f .,a: MInTnie.r'?=f2= `;�_.£�.;,.�..�
k;',.�.
'F
L:�
^:�•
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g ? -�
wiY!-}T ] 'a-�7:hs7
., ..i, .i,
y �yln�
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..; :
i��,#. vof�fvlanths-m,Tie'r;
]«��a:w°.r:�
R" :
-�.,,Z'Sam
x_µ
ss ��
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t a i f' r[,,. ,
- _....1:6Y': -_
.-. ..c �::-.. t. }. ..
f w
..� .�:-s�.r_-_.-••_... ..4. -�1 :..
„
.k..1-Y-.' -, 1..', ....:[.....ft.
- .�'^s• ..s :-
'.�.: .r�...i, Tx'.
a r'r�„� .s.^-,
.11. ^...I:::i,... _-.s, W �Yt.,.
~�7r.< v..� s - °
S. _:S `Yl-.,.«...... �.�:11+"�
� R
t
MAR 11
INR SE +�
If "NO FLOW" or "NO DISCHARGE, Enter "NO FLOW" ar "NO D15CHARGE" for each outfall here. Please make sure to mark the sample period above.
If a value is in excess of the benchmark, or outside the benchmark range (for pH), you must implement the Tier 1 or Tier 2 responses in the General Permit. Tier 2
Monthly sampling shall be done until 3 consecutive samples are below the benchmark or within the benchmark range.
3 TSS benchmark values are 100 mg/l, except when discharging to ORW, HQW, Trout, and PNA waters where they are 50 mg/l.
"For each sampled measurable storm event the total precipitation must be recorded using data from an on -site rain gauge.
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 1 of 2

Part R: Vehicle Maintenance Activity Monitorine Requirements for facilities using > 55 gal of new motor oil/month — averaged over a calendar year.
- _ .i.
t ��,��•�
Outfall� r
No.
r.,,y--2,°':.:.;;�:'i�i%:m'°�°-�''..:fs:i
=Qv J. �1.
s."�6'?.a15,
L+.,,,,"-,,;2•1'p•}
Date:Sample�
=M`r
=;, .�
Collected
i
Y......-—T.�. :d
i...y..
,...: ��_-t"`. �''`
.
"H.
-.�. Standard
�, :;
,..
i _ Units} ��
°
1 . _
.,.f
t F Ks.`aS
f,, k^a�
':� Z�
7 RUN_�°<.
PHrus�n method7otalSuspended
_�56dAYSG7=NEM.
�.�
�i x
w (mg/E1''�(mJ;IL}:fi�Iminutes}
�. z Y;.,:
_ ".'.�',f _
.-i'.'_1":.,y:i'._.,.Z...:..�5,`t�::^1"+a::.::.c•"•:-...vI",:J:f_'^s."Y':
:-:°•-wa c�
�<�i.'''{�'S'+,
..„
�., Sohdsa. �:
»' , , �:>.;_.. s:..'L'
.�.� _ - _ •4
fv:,•
„'. .rim
r . Z
, �'
r=u=Events,
�v
Duration
=
st,
-WY :s:
3t7�r#2.c
I T�� .l�i%� .i
•`._
' �;
S
.r� `
:Total.
a
all
,
=ipiin}
�' �,�_
y�F:X.,.S F i.•
s.?S..T"w,."=.
.3.:i4
:. Y
s ��
—'xlezx.
:New:MotorFOil^
i:."Month)
Usage
3�-g-
.(gal/month); *
.4 �'
`i`�'3"?�
- �..i l"iy'^.. A'yr`. m+i_.T�„-
Y'.:rk^�• -.:i�`.L�"JF�.-.:�:'
=.-"` -
�,IntTierZ 5
�:•�
-x
y ..-..
Monitorin 7
g
=.
kyl
.'J.^a-.lkesz:'..1-'. ",.T'il{.'."'.Ns-�
LM^%�i:tti" T,HKGrit
t
€It;of�Monti�syt,
q a'��
Sam hn
p�. gv �;
::±r:="-..L.°r"�•'r'=Y_,.A.°,
HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES AT ANY ONE OUTFALL (INCLUDING VEHICLE MAINTENANCE)? YES ❑ Nefri
HAVE YOU CONTACTED THE REGION? YES ❑ NOO
REGIONAL OFFICE CONTACT NAME:
Mail OriRinal and one copv of this DMR (including all "No Flow" & "No Discharge" reports) within 30 days of receipt of sample (or at end_ of monitoring period
in case of "No Flow") to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I 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 on my inquiry of the person or persons who manage the system, or
those persons direct re ponsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
am aware that th a are ignificant nalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature of er tee) (Date)
Permit Date: 7/1/2011-60/30/2015 Last Revised 7/13/11
Page 2'of 2

NCDEN
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling out this form, please visit: httl2://portaLncdenr.org/web/wq/ws/sti /­nsib sw#tab-4
Permit No.: NYC/�/ _/_ /_ / _/_/T/ or Certificate of Coverage No.:
Facility Na Y� tL �M C1�/ter
County: J' !r
Inspector:
Date of Inspection:
Time of Inspection:
Phone No.
Total Event Precipitation (inches): _C- i i
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
Ive—mciff—Em
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions, if applicable.
-A "representative storm event" is a storm event that measures greater than 0A inches of rainfall
and that is preceded by at least 72 hours (3 days) in'which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
A "measurable storm event" is a storm event that results in an actual discharge from the
permitted site outfall. The previous measurable storm event must have been at least 72 hours
prior. The 72-hour storm interval does not apply if the permittee is able to document that a shorter
interval is representative for local storm events during the sampling period, and the permittee
obtains am)roval from the local DWO Regional Office.
By this signat ce tify that this report is accurate and complete to the best of my knowledge:
. _' /
(Signature oi`PE—rmittee or Designee)
Pagel of 2
SWU-242, Last modified 10/25/2012

WSA

1. Outfall Description:
Outfall No. 51-2001 Structure (pipe, ditch, etc_.) i 1 Gc
1
Receiving Stream: ki—I Describe the industrial activities. that occur within the outfai�drainarea:
n_ _ _ r
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium; dark) as descriptors: l,A U(-e_ W--;,I =)
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weals chlorine odor, etc.): _ L:1r r'k _
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
0 2 3 4 5
S. Floating Solids: Choose the number which best describes the amount of floating solids in
the stormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
0 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended
solids in the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
1) 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes 0
B. Is there an oil sheen in the stormwater discharge? Yes ( o)
9. Is there evidersce of erosion -or deposition'at the -outfall? Yes, -
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition
may be indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SWU-242. Last modified 10/25/2012

aceMalytical
wwwpecelabs.c=
November 13, 2015
Mr. Johnny Baines
Eastern Environmental Management
PO Box 4030
518 S. Pearl Street
Rocky Mount, NC 27803
RE: Project: DPD - Greenville
Pace Project No.: 92274349
Dear Mr. Baines:
Pace Analytical Services, Inc.
9800 Kincey Ave, Suite 100 _
Huntersville, NC 28078
[phone]
Enclosed are the analytical results for sample(s) received by the laboratory on November 03, 2015.
The results relate only to the samples included in this report. Results reported herein conform to the
most current TNI standards and the laboratory's Quality Assurance Manual, where applicable, unless
otherwise noted in the body of the report.
Analyses were performed at the Pace Analytical Services location indicated on the sample analyte
page for analysis unless otherwise footnoted.
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
Taylor Ezell ,
[e-mail]
Project Manager
Enclosures
cc: Ms. Cathy Baines, Eastern Environmental Management
REPORT OF LABORATORY ANALYSIS
This report shal} not be reproduced, except in full,
without the written consent of Pace Analytical Services, Inc..
Page 1 of 11

a ce Analytical
` www.pswabs.com
Pace Analytical Services, Inc,
9800 KinceyAve. Suite 100
Huntersville, NC 28078
(704+1875-9092
CERTIFICATIONS
Project: DPD - Greenville
Pace Project No.: 92274349
Charlotte Certification Ids
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
FloridalNELAP Certification #: E87627
North Carolina Drinking Water Certification #: 37706
Kentucky UST Certification #: 84
North Carolina Field Services Certification #: 5342
West Virginia Certification #: 357
North Carolina Wastewater Certification #: 12
Virginia/VELAP Certification #: 460221
South Carolina Certification #: 99006001
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
Massachusetts Certification #: M-NCO30
North Carolina Drinking Water Certification #: 37712
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
West Virginia Certification #: 356
Virginia/VEIAP Certification #: 460222
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, Inc., Page 2 of 11

aceAnalytical
www.pacelabs.00m
SAMPLE ANALYTE COUNT
Project: DPD - Greenville
Pace Project No.: 92274349
Pace Analytical Services, Inc.
9800 Kincey Ave. Suite 100
Huntersville, NC 28078 `
[phone]
Analytes
Lab ID Sample ID Method
Analysts
Reported
Laboratory
92274349001 SDO-1 EPA 1664E
JMS
1
PASI-C
SM 2540D
SAM
1
PASI-A
SM 254OF
MJP
1
PASI-A
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, Inc.. Page 3 of 11

aceAnalytical'
www.pacelabsmm
ANALYTICAL RESULTS
Project: DPD - Greenville
Pace Project No.: 92274349
Pace Analytical Services, Inc,
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704�875-9092
Sample: SDO.1
Parameters
Lab ID: 92274349001 Collected: 11/02/15 11:30
Results Units Report Limit DF
Received: 11/03115 09:30 Matrix: Water
Prepared Analyzed CAS No. Qual
HEM, Oil and Grease
Analytical Method: EPA 1664E
Oil and Grease
NO mg[L
5.0 1
11/12/15 07:39
2540D Total Suspended Solids
Analytical Method: SM 2540D
Total Suspended Solids
39.8 mglL
2.6 1
11/04/15 10:20
254OF Total Settleable Solids
Analytical Method: SM 2540F
Total Settleable Solids
ND mLILJhr
0.10 1
11I03115 22:35
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 11 /13/2015 12:44 PM without the written consent of Pace Analytical Services, Inc.. Page 4 of 11

aceAnalytical
L wwwpecelabs.com
QUALITY CONTROL DATA
Project: DPD - Greenville
Pace Project No.: 92274349
Pace Analytical Services, Inc.
9800 Kincey Ave. Suite 100
Huntersville, NC 28078 -
[phone]
QC Batch: GCSV123181
Analysis Method:
EPA 1664B
QC Batch Method: EPA 1664B
Analysis Description:
1664 HEM, Oil and Grease
Associated Lab Samples: 92274349001
METHOD BLANK: 1604434
Matrix: Water
Associated Lab Samples: 92274349001
Blank Reporting
Parameter
Units
Result Limit
Analyzed Qualifiers
Oil and Grease
mg1L
ND 5.0 11/12/15 07:35
LABORATORY CONTROL SAMPLE:
1604435
Spike LCS
LCS % Rec
Parameter
Units
Conc. Result
% Rec Limits Qualifiers
Oil and Grease
mglL
40 33.7
84 78-114
MATRIX SPIKE SAMPLE:
1604436
92275153001 Spike
MS MS % Rec
Parameter
Units
Result Conc.
Result % Rec Limits Qualifiers
Oil and Grease
mglL
ND 40
35.0 88 78-114
Results presented on this page are In the units indicated by the "Units" column except where an alternate unit is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 11113/2015 12:44 PM without the written consent of Pace Analytical Services, Inc.. Page 5 of 11

aceAnalyticaI
wwvrpecelabs.c=
QUALITY CONTROL DATA
Project: DPD - Greenville
Pace Project No.: 92274349
QC Batch: WET141198 Analysis Method: SM 2540D
QC Batch Method: SM 2540D Analysis Description: 2540D Total Suspended Solids
Associated Lab Samples: 92274349001 %
METHOD BLANK: 1598226
Associated Lab Samples: 92274349001
Parameter Units
Total Suspended Solids mg/L
LABORATORY CONTROL_ SAMPLE:
1598227
Parameter
Units
Total Suspended Solids
mg/L
SAMPLE DUPLICATE: 1598228
Parameter
Units
Total Suspended Solids
mg/L
SAMPLE DUPLICATE: 1598229
Parameter
Units
Total Suspended Solids
mglL
Matrix: Water
Blank Reporting
Result Limit Analyzed Qualifiers
ND 2.5 11/04/1510:18
Spike LCS
Conc. Result
250 242
92274504001 Dup
Result Result
78.0 78.0
92274481001 Dup
Result Result
28.4 7.0
Pace Analytical Services, Inc.,
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
LCS % Rec
% Rec Limits Qualifiers
97 90-110
RPD Qualifiers
0
RPD Qualifiers
121 D6
Results presented on this page are In the units Indicated by the "Units" column except where an alternate unit Is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shO not be teproduced, except in full,
Date: 11/13/2015 12:44 PM without the written consent of Pace Analytical Services, Inc.. Page 6 of 11
l

aceAnalytrcal
c www.pawabs.com
QUALITY CONTROL DATA
Project: DPD - Greenville
Pace Project No.: 92274349
QC Batch: WET141192 Analysis Method: SM 254OF
QC Batch Method: SM 254OF Analysis Description: 254OF Total Settable Solids
Associated Lab Samples: 92274349001
METHOD BLANK: 1598139
Associated Lab Samples: 92274349001
Parameter Units
Total Settleable Solids mUUhr
Matrix: Water
Blank Reporting
Result Limit Analyzed Qualifiers
ND 0.10 11/03/1522:35
SAMPLE DUPLICATE: 1598140
92274350001 Dup
Parameter Units Result Result
Total Settleable Solids mIJIJhr ND ND
RPD Qualifiers
Paco Analytical Services, Inc.
9800 Kincey Ave. Suite 500 _
Huntersville• NC 28078
[phone]
Results presented on this page are In the units indicated by the "Units" column except where an alternate unit is presented to the right of the result,
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 11/1312015 12:44 PM without the written consent of Pace Analytical Services, Inc..
Page 7 of 11

aceAnalytical
WWW..pecelebs.com
QUALIFIERS
Project: DPD - Greenville
Pace Project No.: 92274349
DEFINITIONS
DF - Dilution Factor, if reported, represents the factor applied to the reported data due to dilution of the sample aliquot.
ND - Not Detected at or above adjusted reporting limit.
J - Estimated concentration above the adjusted method detection limit and below the adjusted reporting limit.
MDL -Adjusted Method Detection Limit.
PQL - Practical Quantitation Limit.
RL - Reporting Limit.
Pace Analytical Services, Inc.
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
S - Surrogate
1,2-Diphenylhydrazine decomposes to and cannot be separated from Azobenzene using Method 8270. The result for each analyte is
a combined concentration.
Consistent with EPA guidelines, unrounded data are displayed and have been used to calculate % recovery and RPD values.
LCS(D) - Laboratory Control Sample (Duplicate)
MS(D) - Matrix Spike (Duplicate)
DUP - Sample Duplicate
RPD - Relative Percent Difference
INC - Not Calculable.
SG - Silica Gel - Clean -Up
U - Indicates the compound was analyzed for, but not detected.
Acid preservation may not be appropriate for 2 Chloroethyivinyl ether, Styrene, and Vinyl chloride.
Aseparate vial preserved to a pH of 4-5 is recommended in SW846 Chapter 4 for the analysis of Acrolein and Acrylonitrile by EPA
Method 8260.
N- Nitrosodiphenyla mine decomposes and cannot be separated from Diphenylamine using Method 8270. The result reported for
each analyte is a combined concentration.
Pace Analytical is TNI accredited. Contact your Pace PM for the current list of accredited analytes.
TNI - The NELAC Institute.
A 1=IeL'It� ie7:71 �']
PASI-A Pace Analytical Services -Asheville
PASI-C Pace Analytical Services - Charlotte
ANALYTE QUALIFIERS
D6 The relative percent difference (RPD) between the sample and sample duplicate exceeded laboratory control limits.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 1111312015 12:44 PM without the written consent of Pace Analytical Services, Inc.. Page 8 of 11

aceAnalytical
i W"..pacelabs.cam
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Pace Analytical Services, Inc.
9800 Kincey Ave. Suite 100 -
Huntersville, NC 28078
[phone]
Project: DPD - Greenville
Pace Project No.: 92274349
Analytical
Lab lD Samplo ID QC Batch Method QC Batch Analytical Method Batch
92274349001
S130-1
EPA 1664B
GCSV123181
92274349001
SDO-1
SM 2540D
VVET141198
92274349001
SDO-1
SM 254OF
VVET141192
Date: 11/13/2015 12:44 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, Inc..
Page 9 of 11

uocument ivame:
�aceAmlytiCal" Sample
Condition U on Recall
Document Number:
F-CHR-CS-003-rev.16
LIUGUI I ICl It r%vViacm, may IV, LV i V
SCUR Page 1 of 2'
Issuing Authority:
Pace Huntersville Quality Office
Client Name: u 5 f n TA V My,, {-
Courier: Fed EC UPC] USP❑ Clier❑ Commercl;0 Pace Other -
Custody Seal on CoolerlBox Present: ❑ yes Seals intact: ❑ yes
Packing Material: ❑ Bubble Wrap ubble Bags ❑ None [ Other
Thermometer Used: IR Gun 140 Type of Ice: We Blue None
Tema Correction Factor T1 No Correction
Page 2 of 2 Is for Internal Use Only
❑ no
Samples on ice, cooling process has begun
­3
' -
Corrected Cooler Tem 5. C
p•�
Biological Tissue Is Frozen: Yes No rA
Date and Initials of person examining
contents: //• / S
Temp should be above freezing to WC
Comments:
-�,
Chain of Custody Present:
❑ s 6
ONIA
1 •
Chain of Custody Filled Out:
es ONO
❑ IA
2.
Chain of Custody Relinquished:
©Yes
❑N/A
I
Sampler Name & Signature on COC:
01.1-1PNO
❑NIA
4,
Samples Arrived within Hold Time:
17 les PNO
❑NIA
5.
Short Hold Time Analysis <72hr :
es ❑No
❑NIA
6,
Rush Turn Around Time Requested.*
Dyes ® o
©NIA
7• L
Sufficient Volume:
es_ ❑No
❑NIA
$,
Correct Containers Used:
DYes,,O No
❑NIA
g.
-Pace Containers Used:
Yes ❑No
❑NIA
Containers Intact:
tOYes ❑No
❑NIA
10.,
Filtered volume received for Dissolved tests
❑Yes ❑No
❑NA
11,
Sample Labels match COC:
Byes ONO
❑N/A
12.
-Includes dateltime/1D/Anal sis Matrix:
All containers needing preservation have been checked.
Oyes ONO
❑ 6A
1
All containers needing preservation are found to be in
❑Yes ONO.
❑N!A
compliance with EPA recommendation.
exceptions: VOA, collrorm, TOC, O&G, WI-DRO (water)
/
❑Yes �INo
Samples checked for dechlorination:
Dyes ONO
NIA
14.
Heads ace in VOA Vials >6mm :
Dyes ONO
0415.
Trip Blank Present:
Dyes ONO
NrA
A6,
Trip Blank Custody Seals Present
[]Yes ONO
!A
Pace Trip Blank Lot # if purchased):
Client Notification/ Resolution: Field Data Required? Y 1 N
Person Contacted: Date/Time:
Comments/ Resolution:
SCURF Review: Y /. Date: lI }
SRF Review: Hate: t
Note: Whenever there is a dis-t epancy affecting North Carolirla compliance
samples, a copy of this form will be sent to the North Carolina DEHNR
Certification Office (l.e out of hold, Incorrect preservative, out of temp,
incorrect containers)
WOi{ : 92274349
1111111111111111111111
92274349
Page 10 of 11

uucumen[ flame:cet L pP
Sam le Condition Upon Rei CU
�.aceArk?lytica!• -- - —
Document Number.
F-CHR-CS-003-rev.16
Client Name: 5 r~�n rn✓, M y,� �-
LJUC:VII Ier It ncv IJcu. IVIGY IV, Fv 4 V
Page 1 of 2"
Pace Huntersville Ouali Office
Page 2 of 2 is for internal Use Only
Courier: UPL] USP❑ Clier❑ommerc!LJ. Pace. Other
Custody Seal on Cooler/Box Present: Elyes no Seals intact: ❑ yes ❑ no
r,--( Uj Ogg, =
Packing Material: ❑ Bubble Wrap ubbie Bags ❑ None Q Other
Thermometer Used: IR Gun 140 Type of Ice; UWeBlue None Samples on ice, cooling process has begun
Temo Correction Factor T1 No Correction
Corrected Cooler Temp.:�. tJ •C
Temp should be above freezing to 6°C
Biological Tissue is' Frozen: Yes No rp
Comments:
Date and Initials of person examining
contents: _ F> �!• / S
Chain of Custody Present:
❑ s a
❑NIA
1.
Chain of Custody Filled Out:
D,es ❑No
❑ IA
2.
Chain of Custody Relinquished:
Dyes
❑NIA
3.
Sampler Name & Signature on COC:
1311-1—pNo
ONIA
4.
Samples Arrived within Hold Time:
Elles PNo
❑N/A
5.
Short kold Time Analysis <72hr :
es ONO
❑NrA
6.
Rush Turn Around Time Requested:
Dyes o
❑NIA
7. t
Sufficient Volume:
es ONO
❑NIA
S.
Correct Containers Used:
-Pace Containers Used:
i
OYes No
DyesDNo
❑NIA
❑NIA
9.
Containers Intact:
❑Yes ONO
El NIA
10._
Filtered volume received for [Dissolved tests
❑Yes ❑No
❑NIA
11.
Sample Labels match COC:
-includes dateltime/]D/Anal sis Matrix:
E y s ONO
t/
❑NIA
12.
All containers needing preservation have been checked.
All containers needing preservation are found to be in
compliance with EPA recommendation.
exceptions: VOA, oolirorm, TOC, O&G, W-DRO (water)
Dyes ONO
Dyes ❑No
/%
❑Yes 0No
❑NrA
❑NIA
1 .
Samples checked for dechiorination:
❑Yes ❑No
NIA
14.
Headspace in VOA Vials ( >6mm):
Dyes ONO
ofir
15.
Trip Blank Present:
Trip Blank Cuustody Seals Present
Pace Trip Blank Lot # if purchased):
Dyes ONO
❑Yes ONO
NIA
P11 1A
AB.
Client Notification) Resolution: Field Data Required? Y 1 N
Person Contacted: Date/Time:
Comments/ Resolution:
SCURF Review: Date: !f S
SRF Review: Date: I(
Note: Whenever there is a discrepancy affecting North Caroli a compliance
samples, a copy of this form will be sent to the North Carolina DEHNR
Certification Office ( Le out of hold, Incorrect preservative, out of temp,
Incorrect containers)
WOiI : 92274349
1111111111111111111111
92274349
Page 10 of 11

'iPn 1 1cis l'
ace a yt
w .pacelahs.com
Section A Section B
Required Client Information: Required P
CHAIN -OF -CUSTODY 1 Analytical Request Document
The Chain -of -Custody is a LEGAL DOCUMENT. Ail relevant fields must be completed accurately.
Section C
Invoice Info
i C_JI :MLt �c on ��
Add
To'
Purchase Order No.:
Pau
5
Role
'hone:
Fax:
ProjdctNelme: .fr
�� �.
Pau
tequeslod Due DotefTAT:
Project Number.
Pea
Soction D Matrix Codes
Required Chet mtormaeon MATRIX I CODE
a
�
COLLECTED
Drinking water DW
0
zo
water WT
SS22
u
Waste Water Ww
v
m
romPOSITE
coemosne
V
Product P
-
i
START
ENMRAe
ul
SOVSOIitI $L
gVVP
N
SAMPLE ID oil OL
�
�
W
f A-Z, 0.9 ! ,•j Air AR
¢
Sample IDs MUST BE UNIQUE Tissue TS
p
a
4
IF -
Other Or
V
rm•
z
X
OU
J
J
ZE
o
N
DATE
TIME
DATE
TIME
0
Page: f of
nnalion:
1475489
ne: REGULATORY AGENCY
NPDES 17- GROUNDWATER F DRINKING WATER
F- UST r RCRA F OTHER
Site Location A ` `
Gj2� � STATE: ! � L.
Requested Analysis Filtered {Y!N)
y
z
Preservatives }
Z
m
7- z z '2 p 1*,
Pace Project No.! Lab I.D.
ADDITIONAL COMMENTS RELINQUISHED BY! AFFILIATION DATE TIME ACCEPTED BY I AFFILIATION' DATE TIME SAMPLE CONDITIONS
SAMPLER NAME AND SIGNATURE
ORIGINAL
PRINT Name of SAMPLER:
SIGNATURE of SAMPLER:
�Irrpo tam Note: By sinning this lam You are accepting Pxa's NET 30 day payreont terms and agma'vg to Into durgos of 1.5% Por month Im adv :r rk;,3 —t p ld mthe, 30 days.
y o_ r
G m y U Z_ R
2
j 1Y m m= U m� E
f f ~ LO cn
F-ALL-G-020rev.07,45-May-2007