NCG030535_2022 DMR_20220505

NCDEQ Division of Energy, Mineral and Land Resources
Click i`12i�= i4i' Ir15trUCCIUnS
Complete, sign, scan and submit the DMR via the Storrnwater NPDES Permit Data N--Ionitorin2 Rer,or i (DMR) UUload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DEMLR Regional Office.
Certificate of Coverage No. NCG03 0535
Person Collecting Samples: William Edens
Facility Name: ZF Chassis Components, L.L.C.
Laboratory Name: Pace Analytical
Facility County: Catawba
Laboratory Cert. No.: 92592767
Discharge during this period: [a Yes ❑ No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances? ❑ Yes ❑✓ No
If so, which Tier (I, II, or III)?
A copy of this DMR has been uploaded electronically via https:Hedocs.deg.nc.goy/Forms/SW-DMR ✓0 Yes ❑ No
Date Uploaded: 3/24/2022
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
Parameter
Code
Parameter
Outfall #1
Outfall #2
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
03/09/2022
03/09/2022
46529
24-Hour Rainfall in inches
1.0
1.0
C0530
TSS in mg/L (100 or 50*)
3.5
8.3
00400
pH in standard units (6.0-9.0)
6.8
7.0
01119
Copper, total recoverable in mg/L
(0.010)
ND
ND
01051
Lead, total recoverable in mg/ L
(0.075)
ND
ND
01094
Zinc, total recoverable in mg/ L
(0.126)
21.9
24.4
78141
Total Toxic Organics (TTO) in mg/L(i)
(if required)
N/A
N/A
00552
Non -Polar Oil & Grease in mg/L (15)
ND
ND
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic
oil on average
NCOIL
Estimated New Motor/Hydraulic Oil
Usage in gal/month
Outtaus to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of 50 mg/L. All other water classifications have a benchmark of 100 mg/L
Notes (optional): After three days of rainfall ZF Newton received higher ZN reading in the lab report possibly due to wear debris from vehicle tires.
"I certify by my signature below, 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."
:nature of Permittee orDelegated Authorized Individual
Email Address [e-mail]
3/24/2022
Date
Phone Number 828-468-3340

Total Toxic Organics Certification:
"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 leak, spill, or dumping of
concentrated toxic organics into the stormwater or onto 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."
G1/"3/24/2022
Signature of Permittee or Delegated Authorized Individual Date
Email Address [e-mail] Phone Number 828-468-3340

Submission Completed
Page 1 of 2
i_L1)(idj!
M 1c)ffl
Permit and Facility Information:
Please enter the permit number and other details for this upload.
................................. ................................................................................................................. ............... I...........
IMPORTANT. Until your stormwater permit is registered in the eDMR system, an original
signed (not digitally signed) hardcopy of the DMR must be mailed to the address in your
permit, in addition to this electronic upload.
Permit Number* Enter COC or Individual Permit Number (NOT General Permit number with all 0's)
NCG030535
Must begin with NCS or NCG
Facility Name:* ZF Chassis Components, LLC.
County: * Catawba
After uploading here, the original signed hardcopy must be mailed to:
DEQ Mooresville Regional Office
Attn: DEMLR Stormwater Program
610 East Center Avenue
Suite 301
Mooresville, NC 28115
Further contact details at https://deq.nc-gov/contact/regional-
offices/mooresville
Monitoring Period Information:
.............. .................... ......... ..................... ......... .................................... ......... ....................... ......................
.......
Multiple DMRs from sampling periods within the same year can be uploaded together, but please
upload different years with a new submittal form.
Monitoring Period What is the YEAR of the sample date(s)?
Year:.* 2022
Copies of the lab results and/or qualitative (visual) monitoring should NOT be submitted
unless specifically requested by DEQ staff: Only upload completed and signed DMR forms.
**DMR forms should have original signature (not digital) to comply with requirements in 40

Submission Completed Page 2 of 2
OEOR Upi©o12t1
i.;I!ck !ne uploac, button or ,irag and ;lrop ❑;es in -:re io 3Enelcr: cioc,anent.
NCG03-DMR-20210201-DEMLR-SW.pdf 189.561(B
Only PDFs are accepted.
Comments:
* 0 By checking the box and signing box below, I certify that:
• I have given true, accurate, and complete information on this form;
0 1 agree that submission of this Discharge Monitoring Report (DMR) Upload form is a "transaction"
subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions
Act');
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the
NC=General=Statutes(the °Uniform -Electronic Transactions Act°-); -- ---- - — - -
o I understand that an electronic signature on this upload form has the same legal effect and can be
enforced in the same way as a written signature; AND
o I intend to electronically sign and submit this DMR Upload form.
Full Name:* William Edens
Name of person submitting this form
Email Address:* [e-mail]
Phone Number:* 828-468-3340
Signature:'
gall WWI 6e'
Date: * 03/24/2022

/�a'lce A nalj cal
mimpacelabs.com
March 21, 2022
William Edens
ZF Chassis Components LLC
1570 E. P St. Ext.
Newton, NC 28658
RE: Project: STORMWATER SAMPLING
Pace Project No.: 92592767
Dear William Edens:
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Enclosed are the analytical results for sample(s) received by the laboratory on March 10, 2022. The results relate only to
the samples included in this report. Results reported herein conform to the applicable TNI/NELAC Standards and the
laboratory's Quality Manual, where applicable, unless otherwise noted in the body of the report.
The test results provided in this final report were generated by each of the following laboratories within the Pace Network:
• Pace Analytical Services - Asheville
• Pace Analytical Services - Charlotte
• Pace Analytical Services - Peachtree Corners, GA
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
Tyriek Hooks
[e-mail]
[phone]
Project Manager
Enclosures
pyC�CR�o�`�O
BQRA'�0
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 1 of 14

c,
Analytical
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CERTIFICATIONS
Project: STORMWATER SAMPLING
Pace Project No.: 92592767
Pace Analytical Services Charlotte
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
South Carolina Laboratory ID: 99006
South Carolina Certification M 99006001
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
South Carolina Drinking Water Cert. M 99006003
North Carolina Drinking Water Certification M 37706
Florida/NELAP Certification M E87627
North Carolina Field Services Certification M 5342
Kentucky UST Certification M 84
North Carolina Wastewater Certification M 12
Louisiana DoH Drinking Water #: LA029
South Carolina Laboratory ID: 99006
VrginiaNELAP Certification M 460221
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
South Carolina Laboratory ID: 99030
Florida/NELAP Certification M E87648
South Carolina Certification M 99030001
North Carolina Drinking Water Certification #: 37712
VirginiaNELAP Certification M 460222
North Carolina Wastewater Certification M 40
---Pace Analytical Services -Peachtree Corners ---_-
110 Technology Pkwy, Peachtree Comers, GA 30092
North Carolina Certification M 381
Florida DOH Certification M E87315
South Carolina Certification M 98011001
Georgia DW Inorganics Certification M 812
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Without the written consent of Pace Analytical Services, LLC. Page 2 of 14

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SAMPLE ANALYTE COUNT
Project: STORMWATER SAMPLING
Pace Project No.: 92592767
Pace Analytical Services, LLC
9800KinceyAve. Suite 100
Huntersville, NC 28078
[phone]
Analytes
Lab ID Sample ID Method
Analysts
Reported
Laboratory
92592767001 1 EPA 1664B
[CID
1
PASI-C
EPA 200.7
KH
3
PASI-GA
SM 2540D-2015
ZMC
1
PASI-A
EPA 9040C
YEG
1
PASI-A
92592767002 2 EPA 1664E
[CID
1
PASI-C
EPA 200.7
KH
3
PASI-GA
SM 254OD-2015
ZMC
1
PASI-A
EPA 9040C
YEG
1
PASI-A
PASI-A= Pace Analytical Services -Asheville
PASI-C = Pace Analytical Services - Charlotte
PASI-GA = Pace Analytical Services - Peachtree Corners, GA
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Without the written consent of Pace Analytical Services, LLC.
Page 3 of 14

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Analytical
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ANALYTICAL RESULTS
9800 KinceyAve. Suite 100
Huntersville, NC 28078
[phone]
Project: STORMWATER SAMPLING
Pace Project No.: 92592767
Sample: 1 Lab ID: 92592767001 Collected: 03/09/22 11:00 Received: 03/10/22 09:45 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qua[
HEM, Oil and Grease
Analytical Method: EPA 1664B
Pace Analytical Services - Charlotte
Oil and Grease
ND mg/L
5.0 1
03/15/22 00:10
200.7 MET ICP
Analytical Method: EPA 200.7 Preparation Method: EPA 200.7
Pace Analytical Services - Peachtree Corners, GA
Copper
ND ug/L
20.0 1 03/15/22 15:09
03/15/22 22:50 7440-50-8
Lead
ND ug/L
25.0 1 03/15/22 15:09
03/15/22 22:50 7439-92-1
Zinc
21.9 ug/L
20.0 1 03/15/22 15:09
03/15/22 22:50 7440-66-6
_..-_.2540D.Total-Suspended-Solids
Analytical Method:_SM 2540D-20.15 __—__
--
Pace Analytical Services -Asheville
Total Suspended Solids
3.5 mg/L
2.5 1
03/11/22 15:33
9040 pH
Analytical Method: EPA 9040C
Pace Analytical Services -Asheville
pH at 25 Degrees C
6.8 Std. Units
0.10 1
03/14/22 14:17 H3
Date: 03/21/2022 02:35 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Without the written consent of Pace Analytical Services, LLC.
Page 4 of 14

_�laceAnalytical
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ANALYTICAL RESULTS
Project: STORMWATER SAMPLING
Pace Project No.: 92592767
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Sample: 2
Lab ID: 92592767002 Collected: 03/09/22 11:30
Received: 03/10/22 09:45 Matrix: Water
Parameters
Results Units Report Limit DF
Prepared
Analyzed
CAS No. Qua[
HEM, Oil and Grease
Analytical Method: EPA 1664B
Pace Analytical Services - Charlotte
Oil and Grease
ND mg/L 4.9 1
03/15/22 00:10
200.7 MET ICP
Analytical Method: EPA 200.7 Preparation Method: EPA 200.7
Pace Analytical Services - Peachtree Corners, GA
Copper
ND ug/L 20.0 1
03/15/22 15:09
03/15/22 22:54
7440-50-8
Lead
ND ug/L 25.0 1
03/15/22 15:09
03/15/22 22:54
7439-92-1
Zinc
24.4 ug/L 20.0 1
03/15/22 15:09
03/15/22 22:54
7440-66-6
2540D Total Suspended Solids
Analytical Method: SM 254OD-2015
Pace Analytical Services -Asheville
Total Suspended Solids
8.3 mg/L 2.5 1
03/11/22 15:33
9040 pH
Analytical Method: EPA 9040C
Pace Analytical Services -Asheville
pH at 25 Degrees C
7.0 Std. Units 0.10 1
03/14/22 14:22
H3
Date: 03/21/2022 02:35 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 5 of 14

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Analytical
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QUALITY CONTROL DATA
Project: STORMWATER SAMPLING
Pace Project No.: 92592767
QC Batch: 684653 Analysis Method: EPA 1664B
QC Batch Method: EPA 1664E Analysis Description: 1664 HEM, Oil and Grease
Laboratory: Pace Analytical Services - Charlotte
Associated Lab Samples: 92592767001, 92592767002
METHOD BLANK: 3580525 Matrix: Water
Associated Lab Samples: 92592767001, 92592767002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Oil and Grease mg/L ND 5.0 03/15/22 00:10
9800 KinceyAve. Suite 100
Huntersville, NC 28078
[phone]
LABORATORY CONTROL SAMPLE: 3580526
Parameter Units Conc. Result % Rec Limits Qualifiers
Oil and Grease mg/L 40 33.1 83 78-114
MATRIX SPIKE SAMPLE:
Parameter
3580527
Units
50310920002
Result
Spike MS MS % Rec
Conc. Result % Rec Limits Qualifiers
Oil and Grease
mg/L
<5.0
39.6 31.5 77 78-114 M1
SAMPLE DUPLICATE: 3580528
92592634001
Dup
Parameter
Units
Result
Result RPD Qualifiers
Oil and Grease
mg/L
ND
1.3.1
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: 03/21 /2022 02:35 PM without the written consent of Pace Analytical Services, LLC.
Page 6 of 14

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_ e Analytical
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i
QUALITY CONTROL DATA
Project: STORMWATER SAMPLING
Pace Project No.: 92592767
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
QC Batch: 684818 Analysis Method: EPA 200.7
QC Batch Method: EPA 200.7 Analysis Description: 200.7 Metals Total
Laboratory: Pace Analytical Services - Peachtree Corners, GA
Associated Lab Samples: 92592767001, 92592767002
METHOD BLANK: 3581093
Associated Lab Samples: 92592767001, 92592767002
Parameter Units
Copper ug/L
Lead ug/L
Zinc ug/L
Matrix: Water
Blank Reporting
Result Limit Analyzed
ND 20.0 03/15/22 21:47
ND 25.0 03/15/22 21:47
ND 20.0 03/15/22 21:47
Qualifiers
LABORATORY CONTROL SAMPLE:
3581094
Spike
LCS
LCS % Rec
Parameter
Units
Conc.
Result
% Rec Limits Qualifiers
Copper
ug/L
1000
1090
109 85-115
Lead
ug/L
1000
1020
102 85-115
Zinc
ug/L
1000
1020
102 85-115
TRIX SPIKE & MATRIX SPIKE DUPLICATE:
3581095
3581096
MS
MSD
92592577001
Spike
Spike
MS
MSD
MS
MSD
% Rec
Parameter Units
Result
Conc.
Conc.
Result
Result
% Rec
% Rec
Limits RPD
Copper ug/L
634
1000
1000
1640
1660
101
102
70-130 1
Lead ug/L
ND
1000
1000
1040
1040
102
102
70-130 0
Zinc ug/L
281
1000
1000
1280
1270
100
99
70-130 0
Qual
MATRIX SPIKE & MATRIX SPIKE DUPLICATE:
3581097
3581098
MS
MSD
92592785001
Spike
Spike
MS
MSD
MS
MSD
% Rec
Parameter Units
Result
Conc.
Conc.
Result
Result
% Rec
% Rec
Limits RPD Qual
Copper ug/L
ND
1000
1000
1060
1060
105
105
70-130 0
Lead ug/L
ND
1000
1000
1010
1010
100
101
70-130 1
Zinc ug/L
39.7
1000
1000
1060
1050
102
101
70-130 1
Results presented on this page are In the units Indicated by the "Units" column except whore 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: 03/21/2022 02:35 PM without the written consent of Pace Analytical Services, LLC. Page 7 of 14

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QUALITY CONTROL DATA
Project: STORMWATER SAMPLING
Pace Project No.: 92592767
QC Batch: 684209 Analysis Method: SM 254OD-2015
QC Batch Method: SM 254OD-2015 Analysis Description: 2540D Total Suspended Solids
Laboratory: Pace Analytical Services -Asheville
Associated Lab Samples: 92592767001, 92592767002
METHOD BLANK: 3578657 Matrix: Water
Associated Lab Samples: 92592767001, 92592767002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Suspended Solids mg/L ND 2.5 03/11/22 15:29
Pace Analytical Services, LLC
9800 KinceyAve. Suite 100
Huntersville, NC 28078
[phone]
LABORATORY CONTROL SAMPLE: 3578658
- - - --- -- -- - - - -- --- - - -
Spike----LCS- -:-LCS--------%Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Total Suspended Solids mg/L 250 236 94 90-110
SAMPLE DUPLICATE: 3578688
92592920001 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 184 168 9
SAMPLE DUPLICATE: 3578689
92592703001 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 1120 1050 7
Results presented on this page are In the units Indicated by the "Units" column except whore 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: 03/21/2022 02:35 PM without the written consent of Pace Analytical Services, LLC.
Page 8 of 14

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QUALITY CONTROL DATA
Project: STORMWATER SAMPLING
Pace Project No.: 92592767
QC Batch: 684432 Analysis Method: EPA 9040C
QC Batch Method: EPA 9040C Analysis Description: 9040 pH
Laboratory: Pace Analytical Services -Asheville
Associated Lab Samples: 92592767001, 92592767002
SAMPLE DUPLICATE: 3579474
92591530002 Dup
Parameter Units Result Result RPD Qualifiers
pH at 25 Degrees C Std. Units 6.5 6.6 0 H3
SAMPLE DUPLICATE: 3579475
92592767002 Dup
Parameter Units Result Result RPD Qualifiers
pH at 25 Degrees C Std. Units 7.0 7.0 0 H3
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Results presented on this page are In the units Indicated by the "Units" column except where an alto mate unit Is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 03/21/2022 02:35 PM without the written consent of Pace Analytical Services, LLC.
Page 9 of 14

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QUALIFIERS
Project: STORMWATER SAMPLING
Pace Project No.: 92592767
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.
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.
Pace Analytical Services, LLC
9800 KinceyAve. Suite 100
Huntersville, NC 28078
[phone]
PQL - 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 °/a-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 Chloroethylvinyl 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-Nitrosodiphenyla mine decomposes and cannot be separated from Diphenylamine using Method 8270. The result reported for
each analyte is a combined concentration.
Reported results are not rounded until the final step prior to reporting. Therefore, calculated parameters that are typically reported as
"Total" may vary slightly from the sum of the reported component parameters.
Pace Analytical is TNI accredited. Contact your Pace PM for the current list of accredited analytes.
TNI -The NELAC Institute.
ANALYTE QUALIFIERS
H3 Sample was received or analysis requested beyond the recognized method holding time.
M1 Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS) recovery.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 03/21/2022 02:35 PM without the written consent of Pace Analytical Services, LLC. Page 10 of 14

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QUALITY CONTROL DATA CROSS REFERENCE TABLE
Pace Analytical Services, LLC
9800KinceyAve. Suite 100
Huntersville, NC 28078
[phone]
Project:
Pace Project No.:
STORMWATER SAMPLING
92592767
Analytical
Lab ID
Sample ID
QC Batch Method
QC Batch Analytical Method
Batch
92592767001
1
EPA1664B
684653
92592767002
2
EPA1664B
684653
92592767001
1
EPA 200.7
684818 EPA 200.7
684948
92592767002
2
EPA 200.7
684818 EPA 200.7
684948
92592767001
1
SM 2540D-2015
684209
92592767002
2
SM 254OD-2015
684209
92592767001
1
EPA 9040C
684432
92592767002
2
EPA 9040C
684432
Date: 03/21/2022 02:35 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 11 of 14

Document Name:
Document Revised: November 1S, 2021
i aeeAnalytical
Sample Condition Upon Receipt (SOUR)
Page 1 of 2
Document No.:
Issuing Authority:
F-CAR-CS-033-Rev.08
Pace Carolinas Quality Office
Laboratory receiving samples:
Asheville ❑ Eden❑ Greenwood ❑ HuntersvilleW Raleigh[] Mechanicsville[] Atlanta❑ Kernersville❑
j Client Name: W01t : 921592767
- 'V � F t--�1 •� S ' � ��% ;,;�,-� �•/,1 Project a:
Courier: Fed Ex ❑UPS ❑USPS ❑Client II II� I III I I II I� II �II
ElCommercial Pace ❑Other: 92592'l67
i I
Custody Seal Present? ❑Yes '12No Seals intact? Dyes ®No
Date/Initials Person Examining Contents:
Packing Material: ❑Bubble Wrap 12f3ubble Bags ❑None ❑ ' Other Biological Tissue Frozen?
Thermometer: a []Wet ❑Blue Dyes ❑No [ N/A
,,D fR Gun ID: I—kUCte (A ❑None
Type of Ice:
Correction Factor: n
Cooler Temp: 1�, Add/Subtract ("C) (/ Temp should be above freezing to 6'C
Cooler Tem Corrected 'C : r ❑Samples out of temp criteria. Samples on ice, cooling process
p' (,_) i� ttab
USDA Regulated Soli ( OWN/A, water. sample)
egurf
Did samples originate in a -quarantine zone within the United States: CA, NY, or SC (check maps)? -Old samples originate from a foreign source ►internationally,--
.. --- _ -
--
Comments/Discrepancy:
Chain of Custody Present?
b fes
[]NO
[]NIA
1.
Samples Arrived within Hold Time?
�r,,"
IJYes
[]No
❑N/A
2.
Short Hold Time Analysts (e72 hr.)?
❑Yes
171ho
N/A
3.
Rush Turn Around Time Requested?
❑Yes
fNo
❑N/A
4.
Sufficient Volume?
Yes
❑No
❑N/A
5.
Correct Containers Used?
-Pace Containers Used?
Yes
9yes
❑No
ONO
❑N/A
❑N/A
6.'
Containers Intact?
{Yes
[]No
/A
7.
Dissolved analysis: Samples Field Filtered?
❑Yes
[]No
/[f N/A
8.
Sample Labels Match COC7
-Includes Date/lime/ID/Analysis Matriic:
Yes
Y �s�
❑No
❑N/A
9.
Headspace in VOA Vials (55.6mm)?
❑Yes
❑Mo
❑N/A
10.
Trip Blank Present?
Trip Blank Custody Seals Present?
❑Yes
❑Yes
No
[]No
❑N/A .
r!/A
11.
COMMENTS/SAMPLE DISCREPANCY '
Lot ID of split containers:
CLIENT NOTIFICATIDN/RESOLUTION
Person contacted: • Date/fime:
Project Manager SCURF Review:
Project Manager•SRF Review:
Date:
Date:
Field Data Required? Dyes ❑No
Page 12 of 14

�Jce/lnalXical'
Document Name:
Sample Condition Upon Recel
Document No.:
F-CAR-05-033-Rev.08
*Check mark top half of box If pH and/or dechlorination is
verified and within the acceptance range for preservation
samples.
Exceptions: VOA, Coliform, TOC, Oil and Grease, DRO/801S (water) DOC, LLHg
**Bottom half of box Is to list number of bottles
Document Revised: November 15, 2021
t (SCUR) Page 2 of 2
Issuing Authority:
Pace Carolinas Quality Office
Project # W0 o 92',*92/1 6 7
PM: TXH Due Date: 03/24/22
CLIENT: 92-ZFLemford
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pH Adjustment Log for Preserved Samples
Sample ID
Type of Preservative
pH upon receipt
Date preservation adjusted
Time preservation
adjusted
Amount of Preservative
added
Lot H
Note: Whenever there is a discrepancy affecting North Carolina compliance samples, a copy of this torm will be sent to the North Carolina DEHNR Cer{i cation O Ice Le.
Out of hold, incorrect preservative, out of temp, incorrect containers.
Page 13 of 14

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Page 14 of 14