NCS000295_MONITORING INFO_20190806

Fm
STORMWATER DIVISION CODING SHEET
NCS PERMITS
PERMIT NO.
N C � o
DOC TYPE
❑FINAL PERMIT
L� MONITORING REPORTS
❑ APPLICATION
❑ COMPLIANCE
0 OTHER
DOC DATE
❑ ) L:) / () d � U
YYYYMMDD

AUG 0 6 2019
GCiN I r�,Pt- t='ILES
DWR S1rCTIQN
August 1, 2019
JACKSON PAPER
MANUFACTURING
NCDI-,Q, Division of Water Resources, Information Processing Unit
Attn: Central Files/eDMIt
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
RE: Discharge Monitoring Report- .July 2019 'bier Two Report
NPDES Permit No. NCS000295
,Jackson Paper Ni<anufacturing Company
Dear Division of Water Resources:
Please find enclosed Discharge Monitoring Report for Jackson Paper Manufacturing Company
NPDES Permit No. NCS000295 for the month of July 2019.
We sampled Outtall 001 and the receiving water directly upstream and downstream Of Outfall 001
for all parameters listed in our permit on July 22, 2019. There were no benchmark cxceedances at
Outfall 001.
Per our current Tier "rwo response for Outfall 001, we will continue to conduct monthly monitoring
and reporting for all parameters at Oudall 001. Monthly (analytical and qualitative) monitoring
Will continue until three consecutive sample results are below the benchmark values. We will also
continue to monitor for all parameters in the receiving water directly upstream and downstream of
the monitoring point in accordance with the Tier Two response.
NORTH CAROLINA'S LARGEST RECYCLED PAPER PRODUCER
152 wrsr MAINS 1111110 Po Box 6670 St•u,A, SIC 28779 TH {828) 58G-5534 FAX (828) 58G-G755

I certify that based on information and belief formed From reasonable inquiry, the statements and
information in the document are true, accurate, and complete.
Please contact Kiesha Bridges at [phone] ! xt. 226 if you have any questions or need any
additional information.
Sincerely,
arr'FYI lall
C
Vice -President Operations
Jackson Paper Manufacturing Company
Enclosure: Storinwater Discharge Monitoring Report
cc: JPMC File

Storm",ater Discharge Outfall (SDO)
Monitoring Report
Permit Number NCS000295
Facility Name: Jackson Paper Manufacturing Company
Person Collecting Samples: Kiesha Bridges
Certified Laboratory: Pace Analytica] Services, LLC Project# 92438091
Samples Collected During Calendar Year:2019
(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: Jackson
Phone NO. 82$ 586 534 Ext, 226
6AATURE OF PERM TEE OR DESIGNEE)
By this signature, 1 certifv that this report is accurate
and complete to the best of my knowledge.
Oil and Grease
Turbidity
TSS
pli
COD
Benchmark
15
50
(6-9)
120
Benchmark
Benchmark
Benchmark
Benchmark
Date
Result
Result
NIA
Result
Result
Result
Outfall
Exceedance
Exceedance
Exceedance
Exceedance
Sampled
m ,,!L
YIN)
(NTU)
(m IL
YIN
YIN
m 1L
Y/N
7/22/2019
001
ND
No
1.3
16.5
No
6.2
No
ND
No
2:00 m
Creek Pre
7122/19
ND
2,3
16.8
0.4
ND
Nlill
2.10 m
Creek Post
7122119
NLI D
3.6
27.2
6.3
63.4
Mill
2:210m
ND: Not detected at or above adjusted reporting limit.
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? —Yes x No
Mcasureahle
Storm Event?
Yes
0.46

Storm Event Characteristics:
Date: July 22, 2019
iTotal e%ent;precipitaticn,(inche_s_):
Duration of storm event: I hour
Estimated.volume!of rdischarge sampled:
'Time since last rain event: 3 days
Drainage
Area
I
11
111
IV
Area (acres)
Area (0)
Volume (cf)
1.69
73,616
2,822
5.43
236,531
9,067
20.45
890,802
34,147
1.77
77,101
2,956
to lume (gal)
211,108
. 67,821'
_ 2SS;423;
22;107,
Mail Original and one copy to:
Division of Water Ouafity
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
" 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 im risonment fo ik owing violations." -�s ( ( i (
(Signature of Pe ittee) (Datej' I

laceAnalyficale
www.peceiabs.com
July 30, 2019
Kiesha Bridges
Jackson Paper Mfg. Co.
152 West Main St.
Sylva, INC 28779
RE: Project: Stormwater July 2019
Pace Project No.: 92438091
Dear Kiesha Bridges:
Pace Analytical Services, t-t-C
2225 Riverside Dr.
Asheville, NC 28804
(828)254-717Fi
Enclosed are the analytical results for sample(s) received by the laboratory on July 23, 2019. The
results relate only to the samples included in this report. Results reported herein conform to the most
current, applicable TNIINELAC standards and the laboratory's Quality Assurance Manual, where
applicable, unless otherwise noted in the body of the report.
If you have any questions cone erning this report, please feel free to contact me.
Sincerely,
Chris Derouen
[e-mail]
[phone]
Project Manager
Enclosures
cc: Keisha Bridges, Jackson Paper Mfg. Co.
REPORT OF LABORATORY ANALYSIS
This report shall not he reproduced, except in full,
without the written consent of Pace Analytical Services, U-C,
Page 1 of 10

(�IaneAnalyticale
mrw.pacelefu.00m
Project: Stormwater July 2019
Pace Project No.: 92438091
Charlotte Certification IDs
9800 Kincey Ave, Ste 100, Huntersville, NC 28078
LouisianalNELAP Certification # LA17002B
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
Massachusetts Certification #: M-NC030
North Carolina Drinking Water Certification #: 37712
CERTIFICATIONS
South Carolina Certification #: 99006001
FloridaINELAP Certification #: E87627
Kentucky UST Cortification #: 84
VirginiaNELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
VirginiaNELAP Certification #: 460222
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Pace Analytical Services, LLC
2225 Riverside or,
Asheville. NC 288C4
[phone]
Page 2 of 16

6
aceAnaljftal
xwwpacebbs.cvm
Project: Stormwater July 2019
Pace Project No.: 92438091
Lab ID Sample 1D
92438091001 OUTFALL # 1
92438091002 CREEK PRE MILL
92438091003 CREEK POST MILL
Method Analysts
EPA 1664E
JMS
EPA 180.1 Rev 2.0 1993
JP1
SM 2540D-2011
MJP
EPA 9040C
ECH
SM 5220D-2011
GC
EPA 1664E
JMS
EPA 180.1 Rev 2.0 1993
JP1
SM 2540D-2011
MJP
EPA 9040C
ECH
SM 5220D-2011
GC
EPA 1664E
JMS
EPA 180.1 Rev 2.0 1993
JP1
SM 2540D-2011
MJP
EPA 90400
ECH
SM 5220D-2011
GC
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
(828)254a 178
Analytes
Reported Laboratory
1
PASI-C
1
PASI-A
1
PASI-A
1
PASI-A
1
PASI•A
1
PASI-C
1
PASI-A
1
PASI-A
1
PASI-A
1
PASI-A
1
PASI-C
1
PASI-A
1
PASI-A
1
PASI-A
1
PASI-A
Page 3 of 16

lac
eAnalytical
wwwpacebba.eom
ANALYTICAL RESULTS
Pace Analytical Services, LLC
2225 Riverside Dr,
Asheville, NC 28804
(828)254-717ra
Project: Stormwater July 2019
Pace Project No.: 92438091
Sample: OUTFALL # 1 Lab ID: 92438091001 Collected: 07/22/19 14:00 Received: 07123/19 10:22 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
1664 SGT-HEM, TPH
Analytical Method: EPA 1664B
Total Petroleum Hydrocarbons
ND mg1L 4.8 1
07/30119 06:06
180.1 Turbidity
Analytical Method: EPA 180.1 Rev 2.0 1993
Turbidity
1.3 NTU 1.0 1
07/24/19 05:26
2540D Total Suspended Solids
Analytical Method: SM 254OD-2011
Total Suspended Solids
16.5 mg/L 2.5 1
07/25119 16:42
9040 pH
Analytical Method: EPA 9040C
pH at 25 Degrees C
6.2 Std. Units 0.10 1
07/24/19 13:11 H3
5220D COD
Analytical Method: SM 5220D-2011 Preparation Method:
SM 5220D-2011
Chemical Oxygen Demand
ND mg/L 25.0 1
07/24/19 16:55 07/24/19 23:38
REPORT OF LABORATORY ANALYSIS
This report shall not pe reproduced, except in full,
Date' 07/30/2019 04:49 PM without the written consent of Pace Analytical Services, LLC. Page 4 of 16

aceAnalytical
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ANALYTICAL RESULTS
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Project: Stormwater July 2019
Pace Project No.: 92438091
Sample: CREEK PRE MILL Lab ID: 92438091002 Collected: 07/22/19 14:10 Received: 07123119 10:22 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
1664 SGT-HEM, TPH
Analytical Method: EPA 1664B
Total Petroleum Hydrocarbons
ND mglL
4.9 1
07/30/19 06:06
180.1 Turbidity
Analytical Method: EPA 180.1 Rev 2.0 1993
Turbidity
2.3 NTU
1.0 1
07/24/19 05:27
2540D Total Suspended Solids
Analytical Method: SM 254OD-2011
Total Suspended Solids
16.8 mglL
2.5 1
07/25/19 16:42
9040 pH
Analytical Method: EPA 9040C
pH at 25 Degrees C
6.4 Std. Units
0.10 1
07/24/19 13:16 H3
52200 COD
Analytical Method: SM 5220D-2011
Preparation Method: SM 5220D-2011
Chemical Oxygen Demand
ND mglL
25.0 1
07/24/19 16:55 07/24/19 23:38
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 07/3012019 04:49 PM without the written consent of Pace Analytical Services, LLC, Page 5 of 16

Ie
Analj cal
www.pacelaGs.com
ANALYTICAL RESULTS
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Project: Stormwater July 2019
Pace Project No.: 92438091
Sample: CREEK POST MILL Lab ID: 92438091003 Collected: 07122t19 14:20 Received: 07/23/19 10:22 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
1664 SGT-HEM, TPH
Analytical Method: EPA 1664B
Total Petroleum Hydrocarbons
ND mg/L
4,8 1
07/30/19 06:07
180.1 Turbidity
Analytical Method: EPA 180.1 Rev 2.0 1993
Turbidity
3.6 NTU
1.0 1
07/24/19 05:28
2540D Total Suspended Solids
Analytical Method: SM 2540D-2011
Total Suspended Solids
27.2 mg11_
2.6 1
07/25/19 16,42
9040 pH
Analytical Method: EPA 9040C
pH at 25 Degrees C
6.3 Std. Units
0.10 1
07/24/19 13:22 H3
5220D COD
Analytical Method: SM 5220D-2011 Preparation Method: SM 5220D-2011
Chemical Oxygen Demand
63.4 mg/L
25.0 1
07/24/19 16:55 07/24/19 23:38
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 07/30/2019 04:49 PM without the written consent of Pace Analytical Services, LLC. Page 6 of 16

aceAnalytical
wwwpacejabs.wn
QUALITY CONTROL DATA
Project: Stormwater July 2019
Pace Project No.: 92438091
QC Batch: 489150 Analysis Method: EPA 1664E
QC Batch Method: EPA 1664E Analysis Description: 1864 SGT-HEM, TPH
Associated Lab Samples: 92438091001, 92438091002, 92438091003
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, INC 2BB04
[phone]
METHOD BLANK: 2630920 Matrix: Water
Associated Lab Samples: 92438091001, 92438091002, 92438091003
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Petroleum Hydrocarbons i NO 4.8 07/30/19 06:01
LABORATORY CONTROL SAMPLE: 2639921
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Total Petroleum Hydrocarbons mglL 19.2 20.9 108 64-132
MATRIX SPIKE SAMPLE: 2639922
92438314002 Spike MS MS % Rec
Parameter Units Result Conc. Result % Rec Limits Qualifiers
Total Petroleum Hydrocarbons mglL ND 19.2 21.4 110 64-132
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 he reproduced, except in full,
Date: 07/30/2019 04:49 PM without the written consent of Pace Analytical services, LtC. Page 7 of 16

laceAnalyfical"
www.pecdafx9.cdm
QUALITY CONTROL DATA
Project: Stormwaler July 2019
Pace Project No.: 92438091
QC Batch: 488085 Analysis Method: EPA 180.1 Rev 2.0 1993
QC Batch Method: EPA 180.1 Rev 2.0 1993 Analysis Description: 180.1 Turbidity
Associated Lab Samples: 92438091001, 92438091002, 92438091003
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
METHOD BLANK: 2635022 Matrix: Water
Associated Lab Samples: 92438091001, 924380910D2, 92438091003
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Turbidity NTU ND 1.0 07/24/19 05:23
LABORATORY CONTROL SAMPLE: 2635023
Spike LCS LCS % Rec
Parameter Units Cone. Result % Rec Limits Qualifiers
Turbidity NTU 10 9.3 93 90-110
SAMPLE DUPLICATE: 2635024
92438002001 Dup
Parameter Units Result Result RPD Qualifiers
Turbidity NTU ND .53J
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, exoept in full,
Date: 07I30I2019 04:49 PM without the written consent of Pace Analytical Services, LLC. Page 8 of 16

6
acmnalytical
ww.pecebbs.corn
QUALITY CONTROL DATA
Project: Stormwater July 2019
Pace Project No.: 92438091
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
QC Batch? 488456
Analysis Method:
SM 254OD-2011
QC Batch Method: SM 254OD-2011
Analysis Description:
2540D Total Suspended Solids
Associated Lab Samples: 92438091001,
92438091002,
92438091003
METHOD BLANK: 2636715
Matrix:
Water
Associated Lab Samples: 92438091001,
92438091002,
92438091003
Blank
Reporting
Parameter
Units
Result
Limit
Analyzed Qualifiers
Total Suspended Solids
mg/L
ND
2.5 07/25/19 16:41
LABORATORY CONTROL SAMPLE:
2636716
Spike
LCS
LCS % Rec
Parameter
Units
Conc.
Result
% Rec Limits Qualifiers
Tolai Suspended Solids
mg/L
250
242
97 90-110
SAMPLE DUPLICATE: 2636717
92438024001
Dup
Parameter
Units
Result
Result
RPD Qualifiers
Total Suspended Solids
mg/L
120
155 25 D6
SAMPLE DUPLICATE: 2636718
92438466001
Dup
Parameter
Units
Result
Result
RPD Qualifiers
Total Suspended Solids
mg/L
218
224 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: 07/30/2019 04:49 PM without the written consent of Pace Analytical Services, LLC. Page 9 of 16

aceAnalytical
mrwpacelabs.com
QUALITY CONTROL DATA
Project: Stormwater July 2019
Pace Project No.: 92438091
QC Batch: 488121 Analysis Method: EPA 9040C
QC Batch Method: EPA 9040C Analysis Description: 9040 pH
Associated Lab Samples: 92438091001, 92438091002, 92438091003
SAMPLE DUPLICATE: 2635103
92438064001 Dup
Parameter Units Result Result RPD Qualifiers
pH at 25 Degrees C Std. Units 6.3 5.9 5 D6,H3
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[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 he reproduced, except in full,
Date: 07/30/2019 04:49 PM without the written consent of Pace Analytical Services, LLC,
Page 10 of 16

aceAnalytical
nwwpeatlatls.wm
QUALITY CONTROL DATA
Project: Stormwater July 2019
Pace Project No.: 92438091
QC Batch: 488230 Analysis Method: SM 5220D-2011
OC Batch Method: SM 5220D-2011 Analysis Description: 5220D COD
Associated Lab Samples: 92438091001, 92438091002, 92438091003
METHOD BLANK: 2635857 Matrix: Water
Associated Lab Samples: 92438091001, 92438091002, 92438091003
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Chemical Oxygen Demand mglL ND 25.0 07/24/19 23:36
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
(828�254-7176
LABORATORY CONTROL SAMPLE: 2635858
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Chemical Oxygen Demand mg/L 750 751 100 90-110
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2635859
MS
92438078001 Spike
Parameter Units Resuil Conc.
Chemical Oxygen Demand mglL 75.4 100
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2635861
MS
92438120002 Spike
Parameter Units Result Conc.
Chemical Oxygen Demand mg1L 92.1 100
2635860
MSD
Spike MS MSD MS MSD % Rec
Conc. Result Result % Rec % Rec Limits RPD
100 183 183 108 108 90-110 0
2635862
MSD
Spike MS MSD MS MSD % Rec
Conc. Result Result % Rec % Rec Limits RPD
100 195 195 103 103 90-110 0
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: 07/30/2019 04:49 PM without the written consent of Pace Analytical Services, LLC.
Qual
Qual
Page 11 of 16

aceAnaiytical
www.pecerabs.com
QUALIFIERS
Project: Stormwater July 2019
Pace Project No.: 92438091
DEFINITIONS
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
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.
TNTC - Too Numerous To Count
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 -The lowest concentration value that meets project requirements for quantitative data with known precision and
bias for a specific analyte in a specific matrix.
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
NC - 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 Chioroethylvinyl ether.
A separate 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-Nitrosodiphenylamine 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.
LABORATORIES
PASI-A Pace Analytical Services -Asheville
PASI•C Pace Analytical Services - Charlotte
WORKORDER QUALIFIERS
WO: 92438091
(1j Samples 0021003 container did not meet EPA or method requirements.
ANALYTE QUALIFIERS
D6 The precision between the sample and sample duplicate exceeded laboratory control limits.
H3 Sample was received or analysis requested beyond the recognized method holding time.
REPORT OF LABORATORY ANALYSIS
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Date: 07/30/2019 04A9 PM without the written consent of Pace Analytical Services, LLC, Page 12 of 16

O
IaceAnalyfical
(�www.pecelahs.com
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Project:
Pace Project No.:
Stormwater July 2019
92438091
Analytical
LAID
Sample ID
QC Batch Method
QC Batch
Analytical Method
Batch
92438091001
OUTFALL # 1
EPA 1664E
489150
92438091002
CREEK PRE MILL
EPA 1664E
489150
92438091003
CREEK POST MILL
EPA 1664E
489150
92438091001
OUTFALL # 1
EPA 180.1 Rev 2.0 1993
488085
92438091002
CREEK PRE MILL
EPA 180.1 Rev 2.0 1993
488085
92438091003
CREEK POST MILL
EPA 180.1 Rev 2.0 1993
488085
92438091001
OUTFALL # 1
SM 254OD-2011
488456
92438091002
CREEK PRE MILL
SM 254OD-2011
488456
92438091003
CREEK POST MILL
SM 254OD-2011
488456
92438091001
OUTFALL # 1
EPA 9040C
488121
92438091002
CREEK PRE MILL
EPA 9040C
488121
92438091003
CREEK POST MILL
EPA 9040C
488121
92438091001
OUTFALL # 1
SM 52200-2011
488230
SM 5220D-2011
488299
92438091002
CREEK PRE MILL
SM 5220D-2011
488230
SM 5220D-2011
488299
92438091003
CREEK POST MILL
SM 5220D-2011
488230
SM 5220D-2011
488299
Date: 07/30/2019 04:49 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written coRsent of Pace Analylical Services, LLC.
Page 13 of 16

Document Name:
Document Revised: February 7, 2018
2R
J� +
Rc3llCc7l
Sample Condition Upon Receipt(SCUR)
Page 1 of 2
Document No.:
Issuing Authority:
F-CAR•CS-033-Rev.06
Pace Carolinas Quality Office
Laboratory receiving sa les:
Asheville Eden❑ Greenwood ❑ Huntersville❑ Raleigh[] Mechanicsville[]
Client Name: Project WO# : 92433091
r- #:
Courier: ❑Fed Ex ❑UPS Cusps Client
❑ Commercial ❑pace ❑Other:_ 92438091 urn
Custody Seal Present? Dyes F�No Seals Intact? ❑yes Na
Oate/Initials Person Examining Contents: -
Packing Material: []Bubble Wrap Bubble Bags ONone ❑ Other Biological Tissue F zen?
Thermometer t'f []Yes ❑No iI/A
Ella Gun ID: + J �y� Type of Ice: let ❑Blue ❑liars
Cooler Temp (°C): 2-o Correction Factor: Add/Subtract ('C)
Cooler Temp Corrected ('C): Temp should be above freezing to 6`C
❑53mp1es out of temp criteria. Samples on ice, conling process
h3sEegun
USDA Regulated Soil (MINIA, seater sample)
Did samples originate in a quarantine zone within the United States! CA, NY, or SC (check maps)? Old sirra'es originate from a foreign source (Internationa IIy,
Dyes ❑No inr!u&2 Havtaii and Puerto Rico)? r1Yes ❑No
Comments/Discrepancy:
Chain of Custody Present?
des
Cl ,I.
N/A
1.
Samples Arrived within Hold Time?
E Yes
❑1,10
❑aIJA
2.
Short Hold Time Analysls (<72 hr.)?
Yes
to
N/A
3,
Rush Turn Around Time Requested?
es
©No
❑N/A
s.
Sufficient Volume?
EYes
❑ido
❑N/A
S.
Correct Containers Used?
-Pace Containers Used?
❑yes
es
No
r7rd.
❑N/A
[I N/A
6.
(1,'% �� Lt qr'4.%� L
Containers intact?
'es
❑Nlo
N/A
7.
Dissolved analysis: Samples Field Filtered?
Dyes
On
0OA
S.
Sample Labels Match COL?
-Includes Date/Time/ID/Analysis Matrix:
es
❑No
❑N/A
9.
Headspace in VOA Vials (>5-6mm)?
Elyes
❑No
N/A
1o.
Trip Blank Present?
Trip Blank Custody Seals Present?
❑Y@s
Oles
2ho
EJNo
❑N/A
HJA
11.
COMMENTS/SAMPLE DISCREPANCY
Lot ID d split containers:
CLIENT NOTIFICATION/RESOLUTION
Person contacted: Date/Time:
Project Manager SCURF Review: Z
Project Manager SRF Review: Zf
Field Data Required? []Yes rto
Datc: 1J1`
Date: J/'7 ,
Page 14 of 16

Document Name:
Document Revised: February 7, 2018
r
-riiLB�llci�t !Cc?�
Sample Condition Upon Receipt(SCUR)
Page 1 of 2
Document No.:
F-CAR-CS-033-Rev.06
issuing Authority:
Pace Carolinas Quality Office
*Check mark top half of box if pH and/or dechiorination is
verified and within the acceptance range for preservation
samples.
Exceptions: VOA, Coliform, TOC, Oil and Grease, ORa/8015 (:eater) OOC, LLHg
"Bottom half of box is to list number of bottle
Project 1 W®# : 92433091
PM: CD1 Due Date: 08/06/19
CLIENT: 93-Jackson P
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pH Adjustment Log for Preserved Samples
Sample ID
Type of Preservative
pH upon receipt
Date preservation adjusted
TlmepreLr mtlon
adjusted
Amount of Preservative
added
Lot A
Note: Whenever there is a discrepancy affecting North Carolina compliance samples, a copy of this form wI II'ae sect to the North Carolina DEHNR Certification office (i.e.
Out of hold, incorrect preservative, out of temp, incorrect containers.
Page 15 of 16

O
J� .ParPAn;Ivtira1*
CHAIN -OF -CUSTODY 1 Analytical Request Document
The Chain-of-Cus(ody Is a LEGAL DOCUMENT. Ali relevant fields must be completed accurately.
e-e.paceta4s.c0m
81
Page: of Q
Section A Section B Section C
219 314 2
Required Client Inf0miatian: Regtdred Project Irdwrtation: Invoice Inlemratit=
Company:--- Repor,To; t Attention:
Addres - -
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Capy To:
CamDartY Name:
REGULATORY AGENCY
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Address. r
r NPDES I-" GROUND WATER r DRINKING WATER
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PuLchwq Order No.: :*��r �'
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Site Location
STATE:
Roque rrAT:
Project Number.
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ADDITIONAL COMMENTS
RELINQUISHED BY 1 AFFILIATION
DATE
TIME
ACCEPTED 13Y I AFFILIATION
DATE
TIME
SAMPLE CONDITIONS
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SIGNATURE of SAMPLER: F
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'Important Nole: By syrng Shin form you are aocepWg Pato's NET 30 day payment t9rrtL5 and agr, I ng to tste rharpm of 1,5% pm mo -A any Invokes nor paid within 30 gym- F•ALL-0-0211rev.07, 15-May-2007