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HomeMy WebLinkAboutNCG100126_MONITORING INFO_20141212STORMWATER DIVISION CODING SHEET NCG PERMITS PERMIT NO. /V I o L) 1 DOC TYPE ❑HISTORICAL FILE MONITORING REPORTS DOC DATE ❑ �bf� �� � a YYYYMMDD CERTIFICATE OF COVERAGE NO. NCG100126 STORMWATER DISCHARGE OUTFALL (SDO) y y MONITORING REPORT ® ERE V ED DEC 12 2014 CENTRAL FILES DWR SECTION FACILITY NAME Johnston Auto Salvage _ PERSON COLLECTING SAMPLE(S) Alex Ahmady CERTIFIED LABORATORY(S) Pace Analytical Lab # 12 Lab# Part A: Stormwater Benchmarks and Monitoring Results SAMPLES COLLECTED DURING CALENDAR YEAR: 2014 (This monitoring report shall be received by the Division no later than 30 days from the date the facility receives the sampling results from the laboratory.) COUNTY Nash PHONE NO. (919) 269-4743 PLEASE REMEMBER TO SIGN ON THE REVERSE 4 For sampling periods with no discharge, you must submit this discharge monitoring form noting "No Flow" or "No Discharge" within 30 days of the end of that period to comply with permit reporting requirements. Outfali No. Date Sample Collected, mo/dd/year Total Rainfall, inches 00400 00530 - - - - 77023 01051 78141 pH, Standard Units Total Suspended Solids (TSS), mg/L Non -polar O&G/TPH (Method 1664 SGT-HEM), mg/L Ethylene Glycol, mg/L Lead, Total Recoverable, mg/L Total Toxic Organics3, mg/L Benchmark - - 6.0 — 9.01 100/502 15 8,000 (Tiers 2 and 3) 0.03 1.0 Outfall001 09/24/14 D 5.8 111 <5.0 <10.0 <0.0050 NA Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier 1 or Tier 2 responses in the General Permit. 1See If pH values outside this range are recorded in sampled stormwater discharges, but ambient precipitation pH levels are lower, then the lower threshold of this benchmark range is the pH of the precipitation (within instrument accuracy) instead of 6 S.U. Readings from an on -site or local rain gauge (or local precipitation data) must be documented to demonstrate background concentrations were below the benchmark pH range of 6-9. 2See General Permit text to identify whether the more protective benchmark applies for especially sensitive receiving waters. Form SWU-251, last revised October25, 2012 Page 1 of 2 STORMWATER DISCHARGE OUTFALL (SDO) MONITORING REPORT 3For purposes of this permit the definition of Total Toxic Organics is that list as stated in Appendix D, Table II of Chapter 40 Code of Federal Regulations (CFR) Part 122. Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan may request that DWQ waive monitoring of total toxic organics. The solvent management plan shall include a list of the total toxic organic compounds used and the other elements listed in the General Permit. For those facilities allowed such a waiver, the discharger shall sign the following certification statement: Solvent Management Plan Certification Statement "Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit monitoring requirement for total toxic organics (TTO), I certify that to the best of my knowledge and belief, no dumping of concentrated toxic organics into the stormwater or areas which are exposed to rainfall or stormwater runoff has occurred since filing the last discharge monitoring report. I further certify that this facility is implementing all the provisions of the solvent management plan included in the Stormwater Pollution Prevention Plan." Name (Print name) Title (Print title) Signature Mail Original and one copy to: Division of Water Quality Attn: Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 Date "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 directly responsible for gathering the information, the information submitted 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 imprisonment for knowing violations." (Signature of Permittee or Designee) (Date) Form SW U-251, lost revised October 25, 2012 Page 2 of 2 , y e aceAnalytical www.pacelabs.com i October 06, 2014 Darin McClure Mid Atlantic Associates, Inc. RE: Project: JOHNSTON AUTO SALVAGE Pace Project No.: 92218775 Dear Darin McClure: Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 Enclosed are the analytical results for sample(s) received by the laboratory on September 25, 2014. 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, Y Jon D Bradley jon.bradley@pacelabs.com Project Manager Enclosures cc: Joanna Crow, Mid Atlantic Associates, Inc. Chuck Hoffman, Mid Atlantic Associates Beverly Oglesby, Mid Atlantic Associates, Inc. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in futl, without the written consent of Pace Analytical Services, Inc.. Page 1 of 13 Ice Analytical 1 www.pacelabs.com i Project: JOHNSTON AUTO SALVAGE Pace Project No.: 92218775 Indiana Certification IDS 7726 Moller Road, Indianapolis, IN 46266 Illinois Certification #: 200074 Indiana Certification #: C-49-06 Kansas Certification #: E-10247 Charlotte Certification IDS 9800 Kincey Ave. Ste 100, Huntersville, NC 28078 North Carolina Drinking Water Certification #: 37706 North Carolina Field Services Certification #: 5342 North Carolina Wastewater Certification #: 12 South Carolina Certification #: 99006001 Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 Asheville Certification IDs 2225 Riverside Dr., Asheville, NC 28804 Florida/NELAP Certification #: E87648 Massachusetts Certification #: M-NC030 North Carolina Drinking Water Certification M 37712 CERTIFICATIONS Kentucky UST Certification #: 0042 Louisiana/NELAP Certification* 04076 Ohio VAP Certification #: CL-0065 West Virginia Certification #: 330 FloridalNELAP Certification #: E87627 Kentucky UST Certification #: 84 West Virginia Certification #: 357 Virginia/VELAP Certification #: 460221 North Carolina Wastewater Certification #: 40 South Carolina Certification #: 99030001 West Virginia Certification #: 356 VirginiafVELAP 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 13 aceAnalytical ' wyrwpacelabs.com SAMPLE ANALYTE COUNT Project: JOHNSTON AUTO SALVAGE Pace Project No.: 92218775 Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 Lab ID Sample ID Method Analysts Analytts Reported Laboratory 92218776001 OUTFALL NO. 1 EPA 1664B CLV11 1 PASI-C EPA 8015 - Aicohol-Glycol DMT 1 PASI-1 EPA6010 SH1 1 PASI-A SM 2540D TEP 1 PASI-A EPA 9040 MAB 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 13 aceAnalytical www.pacefabs.cem i ANALYTICAL RESULTS Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 Project: JOHNSTON AUTO SALVAGE Pace Project No.: 92218775 Sample: OUTFALL NO. 1 I-ab ID; 92218775001 Collected: 09/24/14 00:00 Received: 09/25/14 09:55 Matrix: Water Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual HEM, Oil and Grease Analytical Method: EPA 1664B Oil and Grease ND mg/L 5.0 1 09/26/14 08:52 8015M Glycols in water Analytical Method: EPA 8015 - Alcohol -Glycol Ethylene glycol ND mg/L 10.0 1 10/05/14 17:18 107-21-1 6010 MET ICP Analytical Method: EPA6010 Preparation Method: EPA 3010 Lead ND ug1L 5.0 1 09/26/14 16:50 09/29/14 20:20 7439.92-1 2540D Total Suspended Solids Analytical Method: SM 2540D Total Suspended Solids 111 mg1L 16.7 1 09/26/14 03:34 9040 pH Analytical Method: EPA 9040 pH 5.8 Std. Units 0.10 1 09/27114 00:48 H6 REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 10/06/2014 04:49 PM without the written consent of Pace Analyticat Services, Inc.. Page 4 of 13 11�;a'ce A nalyticaI iw wpacela6s.com QUALITY CONTROL DATA Project: JOHNSTON AUTO SALVAGE Pace Project No.: 92218775 QC Batch: GCSV119020 Analysis Method: EPA 1664B QC Batch Method: EPA 1664B Analysis Description: 1664 HEM, Oil and Grease Associated Lab Samples: 92218775001 METHOD BLANK: 1293979 Associated Lab Samples: 92218775001 Parameter Units Oil and Grease mg1L Matrix: Water Blank Reporting Result Limit Analyzed Qualifiers ND 5.0 09/26/14 08:44 Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 LABORATORY CONTROL SAMPLE: 1293980 Spike LCS LCS % Rec Parameter Units Conc. Result % Rec Limits Qualifiers Oil and Grease mg1L 40 34.3 86 78-114 MATRIX SPIKE SAMPLE: 1293981 92218775001 Spike MS MS % Rec Parameter Units Result Conc. Result % Rec Limits Qualifiers Oil and Grease mglL NO 40 37.7 94 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: 10/06/2014 04:49 PM without the wntten consent of Pace Analytical Services, Inc.. Page 5 of 13 Ice Analytical www.pacelabs.com QUALITY CONTROL DATA Project: JOHNSTON AUTO SALVAGE Pace Project No.: 92218775 QC Batch: GCSVI13244 Analysis Method: EPA 8015 - Alcohol -Glycol QC Batch Method: EPA 8015 - Alcohol -Glycol Analysis Description: EPA 8015 Modified Associated Lab Samples: 92218775001 METHOD BLANK: 1168208 Associated Lab Samples: Parameter Units Ethylene glycol mg1L LABORATORY CONTROL SAMPLE: 1168209 Parameter Units Ethylene glycol mg1L Pace Analytical Services, Inc. 9800 Kincey Ave, Suite 100 Huntersvilre, NC 28078 (704)875-9092 Matrix: water Blank Reporting Result Limit Analyzed Qualifiers ND 10.0 10105/1416:25 Spike LCS LCS % Rec Cone. Result % Rec Limits Qualifiers 250 233 93 79-129 MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 1168210 1168211 MS MSD 92218775001 Spike Spike MS MSD MS MSD % Rec Parameter Units Result Cone. Cone. Result Result % Rec % Rec Limits RPD Qual Ethylene glycol mg1L ND 250 250 220 222 87 88 67-133 1 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: 10/06/2014 04:49 PM without the written consent of Pace Analytical Services, Inc.. Page 6 of 13 aceAnalytical f w,vwpacefabs.com QUALITY CONTROL DATA Project: JOHNSTON AUTO SALVAGE Pace Project No.: 92218775 QC Batch: MPRP116992 Analysis Method: EPA 6010 QC Batch Method: EPA 3010 Analysis Description: 6010 MET Associated Lab Samples: 92218775001 METHOD BLANK: 1294728 Associated Lab Samples: 92218775001 Parameter Units Lead ug/L LABORATORY CONTROL SAMPLE: 1294729 Parameter Units Lead ug1L Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 Matrix: Water Blank Reporting Result Limit Analyzed Qualifiers NO 5.0 09/29/14 20:11 Spike LCS LCS % Rec Conc. Result % Rec Limits Qualifiers 500 520 104 80-120 MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 1294730 1294731 MS MSD 92218956006 Spike Spike MS MSD MS MSD % Rec Parameter Units Result Conc. Conc. Result Result % Rec % Rec Limits RPD Qual Lead ug/L ND 500 500 499 513 100 103 75-125 3 MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 1294732 1294733 MS MSD 9221895600E Spike Spike MS MSD MS MSD % Rec Parameter Units Result Conc. Conc, Result Result % Rec % Rec Limits RPD Qual Lead ug1L ND 500 500 492 508 98 102 75-125 3 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: 10/06/2014 04:49 PM without the written consent of Pace Analytical Services, Inc.. Page 7of13 aceAnalytrcalm ! www.pacelabs.com i Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875.9092 QUALITY CONTROL DATA Project: JOHNSTON AUTO SALVAGE Pace Project No.: 92218775 QC Batch: WETI33394 Analysis Method: SM 2540D QC Batch Method: SM 2540D Analysis Description: 2540D Total Suspended Solids Associated Lab Samples: 92218775001 METHOD BLANK: 1293964 Associated Lab Samples: 92218775001 Parameter Units Total Suspended Solids mg1L LABORATORY CONTROL SAMPLE: 1293965 Parameter Units Total Suspended Solids mg1L SAMPLE DUPLICATE: 1293966 Parameter Total Suspended Solids SAMPLE DUPLICATE: 1293967 Parameter Total Suspended Solids Matrix: Water Blank Reporting Result Limit Analyzed Qualifiers ND 2.5 09126/14 03:26 Spike LCS LCS % Rec Conc. Result % Rec Limits Qualifiers 250 248 99 90-110 92218938001 Dup Units Result Result RPD Qualifiers mg1L 760 700 8 92218733001 Dup Units Result Result RPD Qualifiers mg/L ND ND Results presented on this page are In the units Indicated by the "Units" column except where an allemate unit is presented to the right of the result. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 10/06/2014 04:49 PM without the written consent of Pace Analytical Services, Inc.. Page 8 of 13 aceAnalytical www.pacelabs.com I Project: JOHNSTON AUTO SALVAGE Pace Project No.: 92218775 QC Batch: WET133409 QC Batch Method: EPA 9040 Associated Lab Samples: 92218775001 SAMPLE DUPLICATE: 1294272 Parameter Units Std. Units pH QUALITY CONTROL DATA Analysis Method: EPA 9040 Analysis Description: 9040 pH 92218344002 Dup Result Result RPD 7.6 7.6 Qualifiers 0 H6 Pace Analytical Services, Inc. 9B00 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 0 Results presented on this page are in the units Indicated by the "Units" colurnn 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: 10/06/2014 04:49 PM without the written consent of Pace Analytical Services, Inc.. Page 9 of 13 aceAnalytical www.pacelabs.com i QUALIFIERS Project: JOHNSTON AUTO SALVAGE Pace Project No.: 92218775 DEFINITIONS Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 DF - Dilution Factor, if reported, represents the factor applied to the reported data due to changes in sample preparation, dilution of the sample aliquot, or moisture content. 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. POL - Practical Quantitation Limit. RL - Reporting Limit. S - Surrogate 1,2-Diphenylhydrazine (8270 listed analyte) decomposes toAzobenzene. Consistent with EPA guidelines, unfounded 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 NC - Not Calculable. SG - Silica Gel - Clean -Up U - Indicates the compound was analyzed for, but not detected. N-Nitrosodiphenylamine decomposes and cannot be separated from Diphenylamine using Method 8270. The result reported for each analyte is a combined concentration. Acid preservation may not be appropriate for 2-Chloroethylvinyl ether, Styrene, and Vinyl chloride. Pace Analytical is TNI accredited. Contact your Pace PM for the current list of accredited analytes. TNI - The NELAC Institute, LABORATORIES PASI-A Pace Analytical Services - Asheville PASI-C Pace Analytical Services - Charlotte PASI-I Pace Analytical Services - Indianapolis ANALYTE QUALIFIERS H6 Analysis initiated outside of the 15 minute EPA recommended holding time. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Dale: 10/06/2014 04:49 PM without the written consent of Pace Analytical Services, Inc.. Page 10 of 13 /�aceAnalyficaI www.pacelabs.com r i QUALITY CONTROL DATA CROSS REFERENCE TABLE Project: JOHNSTON AUTO SALVAGE Pace Project No.: 92218775 Lab ID Sample ID QC Batch Method 92218776001 OUTFALL NO. 1 EPA 1664B 92218775001 OUTFALL NO. 1 EPA 8015 - Alcohol -Glycol 92218775001 OUTFALL NO. 1 EPA 3010 92218775001 OUTFALL NO. 1 SM 2540D 92218775001 OUTFALL NO. 1 EPA 9040 Date: 10/06/2014 04:49 PM Pace Analytical Services, Inc. 9800 Kiacey Ave. Suitet00 Huntersville, NC 28078 (704)875.9092 QC Batch Analytical Method GCSVI19020 GCSVI13244 MPRP116992 EPA 6010 WET133394 WET133409 REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, without the written consent of Pace Analytical Services, Inc.. Analytical Batch CP115326 Page 11 of 13 //9-'Iv170eArk7lytr'0l" i Sample a Condition Upon R�eceil [document Number: F-C R R-C S-003-re v.15 Page 1 of 2 issuing Authority: Pace Huntersville Qualiq Client Name: ssac_ Courier: Zed E ❑ UPS❑ uspS❑ Client❑ CommercialEl Pace Other Custody Seal on CoolerlBox Present: ❑ yes l� no Seals intact: ❑ yes ❑ noVol � ��,"�e r ` '� Packing Material: [�bble V� ❑ Bubble Bags ❑ None ❑ Other �/ Thermometer Used: 94 IR Gun 0 Type of Ice: We Blue None I� Samples on ice, cooling process has begun Temp Correction Factor T1401 No Correction Corrected Cooter'rem C p -- -- Biological Tissue is Frozen: Yes No Date and Initials of person examining contents: Temp should t•e abolre freezing to 6°C Comments: Chain of CustodyF'resen,.: Ekfes ©NO ❑NrA 1. Chain of Custody Filled Out: ClYes C14. ❑NIA 2. P0 ck-;e- /4-Nn1-s Chain of CuAody Relln wished: C3Yes (p�o ❑NrA 3. Sampler Name & Signature on COC. Gres ❑No ❑NIA 4. Samples Arrived within Hold Time: 9jZC--Cyes ❑No ❑NrA 5. Short Hold Time Analysis (<72hr): [�res ❑No ❑NIA 6. Rush Turn Around Time Requested: Dyes ON ❑NIA 7. Sufficient Volume: ❑��YYe�es Clio ❑N1A 8. 'f-�o loof(l IV� Correct Containers Used: L as ❑No • ❑NIA g, -Pace Containers Used: B es ONO ❑NIA Containers Intact: Yes ❑No ❑NIA 10. Filtered volume re,;ei red for Dissolved tests ©Yes ❑No 21NIA 11, _ Sample Labels matcl, COC: ❑Yes too ❑NrA 12. 011A cL �' ° S o tom` l -Includes date;timellDlAnalysis Matrix:_ 3 o� S I y �u J; c, f s h All contalners needing preservation have beer. checked. 2/ Yes ❑No nN1A 13. n J) All containers needing preservation are found to be in Oyes ONO ❑NIA compliance with EPA recommendation. ��/� ❑No exceptions: VOA, coliform, TOC, 08G, W-Cf30 (%vater) L'IYes Samples chocked for dechlorination: Oyes ❑No 3 A 14. Headspace in VOA Vials ( >6mm): ❑Yes ©No ❑NIA 15, Trip Blank Present: ❑yes ❑rio5'IA 16. _ Trip Blank Custody Seals Present ❑Yes ONO 9' IA Pace Trip Blank Lot # (if purchased): Client Notification! Resolution: Fietd Data Required? Y 1 N Person Contacted: Date/Time: Comments/ Resolution: SCURF Re'riew.�Date: `t 'Z'> (L�r;?V+rnl SReview �s� Date: RF IlklJt� �. 14t, Note: Whenever there is a discrepancy affecting North Carolina comp,iance i Samples, a co of this form will be sent to the North Carolina DEHNR 922i8773 : p p5' Certification Office ( i.e out of hold, incorrect preservative, out of temp, incorrect containers) Page 12 of 13 ace Analytical Section A Required Client Information: CHAIN -OE -CUSTODY 1 Analytical Request Document The Chain -of -Custody is a LEGAL DOCUMENT. All relevant fields must be completed accurately. Section 8 section C Required Project Intormation: invoice Information: a Page: of Company: Mid -Atlantic Associates. Inc. Repot To: Chuck Hoffman (choffman@maaonline.com) Attention: Chuck Hoffman Address: 409 Rogers View Court Copy To- Joanna Craw (jcrovin maacinline.corn) Company Name: Mid -Atlantic Associates, inc. REGULATORY AGENCY Raleigh, NC 27610 Address: 409 Rogers View Court, Raleigh, NC I- NPOES r- GROUND WATER F DRiNKING WATER r UST F- RCRA r OTHER Email To: choffman@maaonline.com Purchase order No: R2575.00 Pau chicle - Relerence: Pie 9t9-25D-9918 Fare 919-250-9950 Project Name: Johnston Auto Salvage Pace Prgen Kevin Herring site Location Manager. _ STATE. NC Requested Due OaterrAT; Standard Project Number: R2575,00 Pace Pm01e 0 -_ Requested Analysis Filtered (%( N) Section 0 Valid Matrix Codes IFa = Requ4" Client Information MATRIX coo E Preservatives 3-N Y N Y Dail-0 WATER VN isCOLLECTED WATER wT S u U o m WASTEWATER COMPpSiTE COMPOsrTE ~ -� PRO[M1CY P M START LNa'GRAS J m Z SO4 01.113 SL D1L OL or -i O N Q fD v O } SAMPLE ID mpE V,iP 5 AIR AR (A-Z, OA ! ,-j DrrER oT O U2 Z „ i m i^ w (Y O Sample 10s MUST BE UNIQUE 7i5SUE Ts U X w w O O m r u. ¢¢ O c ci7 Z U m m w r a d 1N DATE TIME DAYS TIME u 2 Z O F,. w 3 Pace Project Nod1 Lab I.D. 1 Outfall No. 1 wr G - 7 141 1 2 J x x- Rainfall (inches): z pH: 3 4 5 5 7 a 9 10 t1 12 AJ30MONAL COMMENTS RELINQUISHED BY ! AFFILIATION DATE TIME ACCEPTED ErY I AFF1UATt0N DATE TIME SAMPLE CIJ=T1ION5 SAMPLER NAME AND SIGNATURE m azo a z - PRINT Name of SAMPLER: ta rD u o} W E ~ u ar t; U SIGNATURE of SAMPLER; D(MM1O0lYY): - /;V-d -lmpenamt Nc1e. ey slgnag des Um you are ectaoling Pace'& NET 30 day part a terms and agreevrg le lair Uwrges at 1.5% Per moth for any Invoices rat paid wahin 30 days. F-ALL-Q-020reV.08, 12-Oct-2007