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Home My WebLink AboutNC0085936_Renewal (Application)_20230525 ROY COOPER �� k 6 Governor ELIZABETH S.BISER ,� � a. -' Secretary RICHARD E.ROGERS,JR. NORTH CAROLINA Director Environmental Quality May 25, 2023 Jerry G. Williams&Son, Inc. Attn: J. Mark Williams, President PO Box 2430 Smithfield, NC 27577-2430 Subject: Permit Renewal Application No. NC0085936 Wet Log Deck Storage site Johnston County Dear Applicant: The Water Quality Permitting Section acknowledges the May 2, 2023, receipt of your permit renewal application and supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made. Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit.The permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a timely manner to requests for additional information necessary to allow a complete review of the application and renewal of the permit. Information regarding the status of your renewal application can be found online using the Department of Environmental Quality's Environmental Application Tracker at: hops://deq.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker If you have any additional questions about the permit, please contact the primary reviewer of the application using the links available within the Application Tracker. Sincere it• Wren edford Administrative Assistant Water Quality Permitting Section cc: Kevin D. Williams, VP ec: WQPS Laserfiche File w/application CIE North Caroline Department at Environmental Quality I Division of Water Resources Raleigh Regional Office 13800 Barrett Drive I Raleigh North Carolina 27609 ..A, e'S 919.791.4200 0%,y V fORN/ P.O. Box 2430 April 26, 2023 524 Brogden Road Smithfield North Carolina 27577 VIA FEDERAL EXPRESS PRIORITY OVERNIGHT DELIVERY 919-934-4115 919-934-4956 Fax Mr. Doug Dowden Supervisor NCDEQ—Div. of Water Resources NPDES Permitting Section—Industrial Permitting Branch 1617 Mail Service Center Raleigh, North Carolina 27699-1617i4�� RE: Renewal of NPDES Permit NC0089536 for Wet Decking Operations j. Jerry G. Williams & Sons, Inc. (JGW) Smithfield, Johnston County,North Carolina aariity Dear Mr. Dowden: Enclosed are one original and two copies of an application for renewal of NPDES Permit NC0089536 (EPA Forms 1 & 2C — Minor Industrial) for the JGW wet decking operations. Included with the renewal application is a Site Location Map,Aerial Photo Locator, Site Property Boundary and analytical reports from sampling of wet decking runoff. Sludge management for our operation consists primarily of managing bark and floating solids captured by screens at the outfall. JGW currently incorporates screened solids into bark and mulch generated by the sawmill, which is sold as by- product. V7 With this application, Jerry G. Williams & Sons, Inc. formally requests renewal of � , t NPDES Permit NC0089536. Should you have any questions, please call me at (919) 934-4115. Sincerely, JERRY G. WILLIAMS & SONS, INC. $19 RECEIVED Kevin D. Williams 1OOO MANUf,�CT Vice-President MAY 0 2 2023 o� �UEnclosures �✓ NCDEQIDWR/NPDES 4 SOCUTO# iimiirNcrA LEAF ENVIRONMENTAL & ENGINEERING , P . C . P.O. BOX 14609 • RTP, NC 27709 PHONE 919.484.8536 FAX 919.484-8540 RENEWAL OF NPDES PERMIT NC0089536 FOR WET DECKING OPERATIONS FOR JERRY G. WILLIAMS & SONS, INC. (JGW) SMITHFIELD, JOHNSTON COUNTY, NC RECEIVED MAY 0 2 2023 NCDEQ/DWR/NPDES April 25, 2023 ISLEAF ENVIRONMENTAL & ENGINEERING , P . C . P.O. BOX 14609 • RTP, NC 27709 PHONE 919.484.8536 FAX 919-484.8540 RENEWAL OF NPDES PERMIT NC0089536 FOR WET DECKING OPERATIONS FOR JERRY G. WILLIAMS & SONS, INC. (JGW) SMITHFIELD, JOHNSTON COUNTY, NC April 25, 2023 TABLE OF CONTENTS EPA FORM 1: GENERAL INFORMATION EPA FORM 2C: EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS FIGURES ANALYTICAL Leaf Environmental and Engineering,P.C. EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. OMB No.2040-0004 Form U.S.Environmental Protection Agency 1 = EPA Application for NPDES Permit to Discharge Wastewater NPDES GENERAL INFORMATION SECTION 1.ACTIVITIES REQUIRING AN NPDES PERMIT(40 CFR 122.21(f)and(f)(1)) 1.1 Applicants Not Required to Submit Form 1 Is the facility a new or existing publicly owned Is the facility a new or existing treatment works 1.1.1 12 treatment works? 1. . treating domestic sewage? If yes,STOP. Do NOT complete ❑✓ No If yes,STOP. Do NOT No Form 1.Complete Form 2A. complete Form 1.Complete Form 2S. 1.2 Applicants Required to Submit Form 1 }. 1.2.1 Is the facility a concentrated animal feeding 1.2.2 Is the facility an existing manufacturing, operation or a concentrated aquatic animal commercial,mining,or silvicultural facility that is a production facility? currently discharging process wastewater? oYes 4 Complete Form 1 2 No ❑✓ Yes 4 Complete Form ❑ No a and Form 2B. 1 and Form 2C. 1.2.3 Is the facility a new manufacturing,commercial, 1.2.4 Is the facility a new or existing manufacturing, mining,or silvicultural facility that has not yet commercial, mining,or silvicultural facility that commenced to discharge? discharges only nonprocess wastewater? Yes 4 Complete Form 1 ❑✓ No D Yes-4 Complete Form 11 No ce and Form 2D. 1 and Form 2E. ic 1.2.5 Is the facility a new or existing facility whose discharge is composed entirely of stormwater associated with industrial activity or whose discharge is composed of both stormwater and non-stormwater? El Yes 4 Complete Form 1 ❑✓ No and Form 2F unless exempted by 40 CFR 122.26(b)(14)(x)or b 15 . SECTION 2.NAME,MAILING ADDRESS,AND LOCATION(40 CFR 122.21(f)(2)) 2.1 Facility Name Jerry G.Williams&Sons,Inc. `0 2.2 EPA Identification Number y co U 0 110018833994 a 2.3 Facility Contact Name(first and last) Title Phone number a Kevin Williams VP (919)934-4115 cri Email address kdwilliams@jgwlumber.com 2 2.4 Facility Mailing Address co Street or P.O.box PO Box 2430 City or town State ZIP code Smithfield NC 27577 EPA Form 3510-1(revised 3-19) Page 1 EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. OMB No.2040-0004 N 7, 2.5 Facility Location a . Street,route number,or other specific identifier . a 524 Brogden Road o County name County code(if known) 4 Johnston E 2 City or town State ZIP code z Smithfield NC 27577 SECTION 3.SIC AND NAICS CODES(40 CFR 122.21(f)(3)) 3.1 SIC Code(s) Description(optional) 2421 Sawmills&Planing Mills,General v 0 U N U 3.2 NAICS Code(s) Description(optional) -o 321113 Sawmills U N SECTION 4.OPERATOR INFORMATION(40 CFR 122.21(f)(4)) 4.1 Name of Operator Kevin Williams co 4.2 Is the name you listed in Item 4.1 also the owner? ❑✓ Yes ❑ No 4.3 Operator Status ❑ Public—federal ❑ Public—state 0 Other public(specify) o ❑✓ Private ❑ Other(specify) 4.4 Phone Number of Operator (919)934-4115 4.5 Operator Address 0 Street or P.O. Box E 524 Brogden Road `o c 0 City or town State ZIP code o 0 Smithfield NC 27577 co Email address of operator kdwilliams@jgwlumber.com SECTION 5.INDIAN LAND(40 CFR 122.21(f)(5)) c 5.1 Is the facility located on Indian Land? c `J ❑Yes ❑✓ No EPA Form 3510-1(revised 3-19) Page 2 EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. OMB No.2040-0004 SECTION 6.EXISTING ENVIRONMENTAL PERMITS(40 CFR 122.21(f)(6)) 6.1 Existing Environmental Permits(check all that apply and print or type the corresponding permit number for each) m NPDES(discharges to surface ❑ RCRA(hazardous wastes) ❑ UIC(underground injection of N water) fluids) o = NC0085936-NCG210290 w a. ❑ PSD(air emissions) 0 Nonattainment program(CAA) ❑ NESHAPs(CAA) rn w ❑ Ocean dumping(MPRSA) ❑ Dredge or fill(CWA Section 404) ❑✓ Other(specify) Air Permit 03235R13 SECTION 7.MAP(40 CFR 122.21(f)(7)) 7.1 Have you attached a topographic map containing all required information to this application?(See instructions for specific requirements.) RI ❑✓ Yes ❑ No ❑ CAFO—Not Applicable(See requirements in Form 2B.) SECTION 8.NATURE OF BUSINESS(40 CFR 122.21(f)(8)) 8.1 Describe the nature of your business. We buy pine and hardwood logs from various suppliers.Logs are unloaded and sealed,then they are sorted by series.Logs are then put into rows on concrete pads.We wet deck these logs from around April to December to prevent blue stain in logs.Logs are then put into our sawmill,de-barked and sawn into lumber.Grade lumber is stacked and placed on yard to air dry then after the lumber is air dried,we place it into dry kilns for further drying to co 6-8%moisture content for hardwood&14-19%for pine lumber.Lumber is then taken off stacking sticks,graded& packaged for sale. is z SECTION 9.COOLING WATER INTAKE STRUCTURES(40 CFR 122.21(f)(9)) 9.1 Does your facility use cooling water? ❑ Yes ❑✓ No 4 SKIP to Item 10.1. w 9.2 Identify the source of cooling water.(Note that facilities that use a cooling water intake structure as described at a, 40 CFR 125,Subparts I and J may have additional application requirements at 40 CFR 122.21(r).Consult with your • "' NPDES permitting authority to determine what specific information needs to be submitted and when.) o °J 0 Y U +j SECTION 10.VARIANCE REQUESTS(40 CFR 122.21(f)(10)) 10.1 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)?(Check all that apply.Consult with your NPDES permitting authority to determine what information needs to be submitted and when.) c ❑ Fundamentally different factors(CWA ❑ Water quality related effluent limitations(CWA Section ce Section 301(n)) 302(b)(2)) ❑ Non-conventional pollutants(CWA ❑ Thermal discharges(CWA Section 316(a)) Section 301(c)and(g)) ❑✓ Not applicable EPA Form 3510-1(revised 3-19) Page 3 EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. OMB No.2040-0004 SECTION 11.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d)) 11.1 In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application. For each section,specify in Column 2 any attachments that you are enclosing to alert the permitting authority.Note that not all applicants are required to provide attachments. Column 1 Column 2 ❑✓ Section 1:Activities Requiring an NPDES Permit ❑ w/attachments ❑✓ Section 2:Name, Mailing Address,and Location ❑ w/attachments ❑✓ Section 3:SIC Codes ❑ wl attachments ❑✓ Section 4:Operator Information 0 w/attachments ❑✓ Section 5:Indian Land ❑ wl attachments ❑✓ Section 6:Existing Environmental Permits 0 w/attachments 0Section 7:Map ❑✓ P pographic ❑✓ wl additional attachments o ❑✓ Section 8: Nature of Business ❑ w/attachments w ❑ Section 9:Cooling Water Intake Structures ❑ w/attachments 0 Section 10:Variance Requests 0 wl attachments w 0Section 11: Checklist and Certification Statement Elw/attachments Y 11.2 Certification Statement U 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 fine and imprisonment for knowing violations. Name(print or type first and last name) Official title J.Mark Williams President Signat re A t�/} Date signed 412-7/2-3 EPA Form 3510-1(revised 3-19) Page 4 EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. OMB No.2040-0004 Form U.S.Environmental Protection Agency 2C —rEPA Application for NPDES Permit to Discharge Wastewater NPDES EXISTING MANUFACTURING,COMMERCIAL,MINING,AND SILVICULTURE OPERATIONS SECTION 1.OUTFALL LOCATION(40 CFR 122.21(g)(1)) 1.1 Provide information on each of the facility's outfalls in the table below. Numbelr Receiving Water Name Latitude Longitude 0 001 UT to NEUSE RIVER 35° 29' 30" N 78° 21' 14" W r ° ° ° ° SECTION 2.LINE DRAWING(40 CFR 122.21(g)(2)) o, 2.1 Haveyou attached a line drawingto this application that shows the water flow throughyour facilitywith a water PP 9 3 balance?(See instructions for drawing requirements. See Exhibit 2C-1 at end of instructions for example.) J ` ❑✓ Yes ❑ No SECTION 3.AVERAGE FLOWS AND TREATMENT(40 CFR 122.21(g)(3)) 3.1 For each outfall identified under Item 1.1, provide average flow and treatment information.Add additional sheets if necessary. "Outfall Number" 001 Operations Contributing to Flow Operation Average Flow WET DECKING 0.450 mgd w c mgd mgd a mgd Treatment Units Description Code from Final Disposal of Solid or co (include size,flow rate through each treatment unit, Liquid Wastes Other Than Table 2C-1 Discharge retention time,etc.) by FLOW RATE=650,000 gpd(max) 1-T BLEND&SELL SOLIDS EPA Form 3510-2C(Revised 3-19) Page 1 EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. OMB No.2040-0004 3.1 "Outfall Number" cont. Operations Contributing to Flow Operation Average Flow mgd mgd mgd mgd Treatment Units Description Code from Final Disposal of Solid or (include size,flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than retention time,etc.) by Discharge v d 0 U N E: is y H 0 "Outfall Number" Operations Contributing to Flow U- Operation Average Flow mgd cu > ' mgd mgd mgd Treatment Units Description Code from Final Disposal of Solid or (include size,flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than retention time,etc.) by Discharge 3.2 Are you applying for an NPDES permit to operate a privately owned treatment works? d ❑ Yes ❑✓ No 4 SKIP to Section 4. N3.3 Have you attached a list that identifies each user of the treatment works? ❑ Yes ❑ No EPA Form 3510-2C(Revised 3-19) Page 2 EPA Identification Number NPDES Permit Number FacilityName Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. OMB No.2040-0004 SECTION 4.INTERMITTENT FLOWS(40 CFR 122.21(g)(4)) 4.1 Except for storm runoff, leaks,or spills,are any discharges described in Sections 1 and 3 intermittent or seasonal? ❑✓ Yes ❑ No 4 SKIP to Section 5. 4.2 Provide information on intermittent or seasonal flows for each applicable outfall.Attach additional pages,if necessary. Outfall Operation Frecuency Flow Rate Number (list) Average Average Long-Term Maximum Duration Days/Week MonthslYear Average Daily WET DECKING 7 days/week 7 months/year 0.450 mgd 0.650 mgd 213 days 001 days/week months/year mgd mgd days u_ days/week months/year mgd mgd days days/week months/year mgd mgd days m days/week months/year mgd mgd days days/week months/year mgd mgd days days/week months/year mgd mgd days days/week months/year mgd mgd days days/week months/year mgd mgd days SECTION 5.PRODUCTION(40 CFR 122.21(g)(5)) 5.1 Do any effluent limitation guidelines(ELGs)promulgated by EPA under Section 304 of the CWA apply to your facility? ❑✓ Yes 0 No 4 SKIP to Section 6. 5.2 Provide the following information on applicable ELGs. ELG Category ELG Subcategory Regulatory Citation SUBCHAPTER N WET STORAGE(SUBPART I) 40 CFR PART 429 U n d Q 5.3 Are any of the applicable ELGs expressed in terms of production(or other measure of operation)? ❑ Yes ❑✓ No 4 SKIP to Section 6. 0 5.4 Provide an actual measure of daily production expressed in terms and units of applicable ELGs. Outfall Unit of Operation,Product,or Material Quantity per Day Number Measure CO 0 O a EPA Form 3510-2C(Revised 3-19) Page 3 EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. OMB No.2040-0004 SECTION 6.IMPROVEMENTS(40 CFR 122.21(g)(6)) 6.1 Are you presently required by any federal,state,or local authority to meet an implementation schedule for constructing, upgrading,or operating wastewater treatment equipment or practices or any other environmental programs that could affect the discharges described in this application? ❑ Yes ❑✓ No 4 SKIP to Item 6.3. 6.2 Briefly identify each applicable project in the table below. Affected Final Compliance Dates Brief Identification and Description of Outfalls Source(s)of c Project (list outfall Discharge Required Projected c number) E a <o N d a 01 d 6.3 Have you attached sheets describing any additional water pollution control programs(or other environmental projects that may affect your discharges)that you now have underway or planned?(optional item) ❑ Yes ❑✓ No ❑ Not applicable SECTION 7.EFFLUENT AND INTAKE CHARACTERISTICS(40 CFR 122.21(g)(7)) See the instructions to determine the pollutants and parameters you are required to monitor and,in turn,the tables you must complete. Not all applicants need to complete each table. Table A.Conventional and Non-Conventional Pollutants 7.1 Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of your outfalls? ❑ Yes ❑✓ No 4 SKIP to Item 7.3. 7.2 If yes,indicate the applicable outfalls below.Attach waiver request and other required information to the application. Outfall Number Outfall Number Outfall Number 7.3 Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been requested and attached the results to this application package? o 0 Yes ❑ No;a waiver has been requested from my NPDES permitting authority for all pollutants at all outfalls. iS Table B.Toxic Metals,Cyanide,Total Phenols,and Organic Toxic Pollutants . 7.4 Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories listed in Exhibit 2C-3?(See end of instructions for exhibit.) ❑ Yes ✓❑ No 4 SKIP to Item 7.8. 7.5 Have you checked"Testing Required"for all toxic metals,cyanide,and total phenols in Section 1 of Table B? ❑ Yes ❑ No 7.6 List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s)identified in Exhibit 2C-3. Primary Industry Category Required GC/MS Fraction(s) (Check applicable boxes.) ❑Volatile 0 Acid ❑Base/Neutral 0 Pesticide ❑Volatile 0 Acid 0 Base/Neutral 0 Pesticide ❑Volatile ❑Acid 0 Base/Neutral 0 Pesticide EPA Form 3510-2C(Revised 3-19) Page 4 EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. OMB No.2040-0004 7.7 Have you checked"Testing Required"for all required pollutants in Sections 2 through 5 of Table B for each of the GC/MS fractions checked in Item 7.6? ❑ Yes ❑ No 7.8 Have you checked"Believed Present"or"Believed Absent"for all pollutants listed in Sections 1 through 5 of Table B where testing is not required? ❑✓ Yes ❑ No 7.9 Have you provided(1)quantitative data for those Section 1,Table B, pollutants for which you have indicated testing is required or(2)quantitative data or other required information for those Section 1,Table B,pollutants that you have indicated are"Believed Present"in your discharge? ❑ Yes ❑ No n 7.10 Does the applicant qualify for a small business exemption under the criteria specified in the instructions? Yes 4 Note that you qualify at the top of Table B, ✓ No -0 ❑ then SKIP to Item 7.12. ❑ == 7.11 Have you provided(1)quantitative data for those Sections 2 through 5,Table B,pollutants for which you have c determined testing is required or(2)quantitative data or an explanation for those Sections 2 through 5,Table B, pollutants you have indicated are"Believed Present"in your discharge? ❑✓ Yes ❑ No d Table C.Certain Conventional and Non-Conventional Pollutants 7.12 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed on Table C s for all outfalls? Y ❑✓ Yes ❑ No ' 7.13 Have you completed Table C by providing(1)quantitative data for those pollutants that are limited either directly or -0 indirectly in an ELG and/or(2)quantitative data or an explanation for those pollutants for which you have indicated "Believed Present"? ❑✓ Yes ❑ No w Table D.Certain Hazardous Substances and Asbestos 7.14 Have you indicated whether pollutants are"Believed Present"or"Believed Absent"for all pollutants listed in Table D for all outfalls? ❑✓ Yes ❑ No 7.15 Have you completed Table D by(1)describing the reasons the applicable pollutants are expected to be discharged and(2)by providing quantitative data,if available? ❑✓ Yes ❑ No Table E.2,3,7,8-Tetrachlorodibenzo-p-Dioxin(2,3,7,8-TCDD) 7.16 Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions,or do you know or have reason to believe that TCDD is or may be present in the effluent? ❑ Yes 4 Complete Table E. ❑✓ No 4 SKIP to Section 8. 7.17 Have you completed Table E by reporting qualitative data for TCDD? ❑ Yes ❑✓ No SECTION 8.USED OR MANUFACTURED TOXICS(40 CFR 122.21(g)(9)) 8.1 Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as an intermediate or final product or byproduct? ,`3 ❑ Yes ElNo 4 SKIP to Section 9. 8.2 List the pollutants below. . 0 1. 4. 7. 0 2. 5. 8. 3. 6. 9. EPA Form 3510-2D(Revised 3-19) Page 5 EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. OMB No.2040-0004 SECTION 9.BIOLOGICAL TOXICITY TESTS(40 CFR 122.21(g)(11)) 9.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made within the last three years on(1)any of your discharges or(2)on a receiving water in relation to your discharge? 0 Yes ❑✓ No 4 SKIP to Section 10. if? 9.2 Identify the tests and their ourposes below. Submitted to NPDES .X Test(s) Purpose of Test(s) Permitting Authority? Date Submitted ❑ Yes ❑ No _ O in ❑ Yes ❑ No ❑ Yes ❑ No SECTION 10.CONTRACT ANALYSES(40 CFR 122.21(g)(12)) 10.1 Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm? 0 Yes ❑ No-4 SKIP to Section 11. 10.2 Provide information for each contract laboratory or consulting firm below. Laboratory Number 1 Laboratory Number 2 Laboratory Number 3 Name of laboratory/firm PACE ANALYTICAL N Laboratory address 6701 CONFERENCE DRIVE RALEIGH,NC 27607 to to 0 Phone number (919)834-4984 Pollutant(s)analyzed COLOR,PH,TSS,BOD5,OIL& GREASE,FECAL COLI FORMS NITROGEN(AMMONIA,TKN, NITRATE-NITRITE); PHOSPHEROUS,COD,TOC SECTION 11.ADDITIONAL INFORMATION(40 CFR 122.21(g)(13)) 11.1 Has the NPDES permitting authority requested additional information? ❑ Yes ❑✓ No 4 SKIP to Section 12. 0 E 11.2 List the information requested and attach it to this application. 0 1. 4. Co 0 2. 5. 3. 6. EPA Form 3510-2C(Revised 3-19) Page 6 r Approved 1 EPA Identification Number NPDES Permit Number Facility Name Form App o ed 03/05/ 9 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. OMB No.2040-0004 SECTION 12.CHECKLIST AND CERTIFICATION STATEMENT(40 CFR 122.22(a)and(d)) 12.1 In Column 1 below, mark the sections of Form 2C that you have completed and are submitting with your application. For each section,specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not all applicants are required to complete all sections or provide attachments. Column 1 Column 2 ❑✓ Section 1: Outfall Location ❑ w/attachments ❑✓ Section 2:Line Drawing ❑ w/line drawing ❑✓ wl additional attachments Section 3:Average Flows and w/list of each user of ❑✓ Treatment ❑ wl attachments ❑ privately owned treatment works ❑✓ Section 4: Intermittent Flows ❑ wl attachments ❑✓ Section 5:Production ❑ wl attachments w/optional additional 12Section 6: Improvements ❑ w/attachments ❑ sheets describing any additional pollution control plans ❑ w/request for a waiver and ❑ w/explanation for identical supporting information outfalls d w/small business exemption wl other attachments d ❑ request ❑ ❑ Section 7: Effluent and Intake ❑ w/Table A ❑✓ w/Table B Characteristics 0 ❑✓ wl Table C ❑✓ wl Table D d ❑ wl Table E ❑✓ w/analytical results as an (-) attachment c ❑ Section 8:Used or Manufactured ❑ wl attachments y Toxics • Section 9: Biological Toxicity d ❑ Tests ❑ w/attachments U ❑✓ Section 10:Contract Analyses ❑ w/attachments ❑ Section 11:Additional Information ❑ wl attachments ✓❑ Section 12:Checklist and ❑ w/attachments Certification Statement 12.2 Certification Statement 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 fine and imprisonment for knowing violations. Name(print or type first and last name) Official title J.MARK WILLIAMS PRESIDENT Signatur Date si ned 140-tit .' ..�-- q z?/Z3 EPA Form 3510-2C(Revised 3-19) Page 7 This page intentionally left blank. EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE A.CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(iii))l Effluent Intake Waiver (Optional) Pollutant Requested Units Maximum Maximum Long-Term (if applicable) (specify) Daily Monthly Average Daily Number of Long-Term Number of Discharge Discharge Discharge Analyses Average Value Analyses (required) (if available) (if available) ❑ Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall. Biochemical oxygen demand Concentration mg/L 9.5 1 1' (BOD5) ❑ Mass lbs/day 51.5 Chemical oxygen demand Concentration mg/L 61.4 1 2. ❑ (COD) Mass lbs/day 333.0 Concentration mg/L 15.4 1 3. Total organic carbon(TOC) 0 Mass lbs/day 83.5 Concentration mg/L 45.0 1 4. Total suspended solids(TSS) ❑ - Mass lbs/day 244.1 Concentration mg/L 0.10 1 5. Ammonia(as N) ❑ Mass lbs/day 0.54 6. Flow ❑ Rate mgd 0.650 1 Temperature(winter) ❑ °C °C — 7. Temperature(summer) 0 °C °C 23 1 pH(minimum) ❑ Standard units s.u. 7.6 1 8. pH(maximum) ❑ Standard units S.U. 7.6 1 1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or required under 40 CFR chapter I,subchapter N or 0. See instructions and 40 CFR 122.21(e)(3). EPA Form 3510-2C(Revised 3-19) Page 9 This page intentionally left blank. EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. ow. OMB No.2040-0004 TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))l Presence or Absence Intake (check one) Effluent (optional) Pollutant/Parameter Testing Units Long-Term (and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number Present Absent Daily Monthly Daily of Term of Discharge a Dischargef available) Discharge Analyses AverageValue Analyses (required)) ( (if available) Check here if you qualify as a small business per the instructions to Form 2C and,therefore,do not need to submit quantitative data for any of the organic toxic pollutants in Sections 2 through 5 of this table. Note,however,that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge. Section 1.Toxic Metals,Cyanide,and Total Phenols 1.1 Antimony,total 0Concentration 0 El (7440-36-0) Mass 1.2 Arsenic,total ❑ Concentration El (7440-38-2) Mass Beryllium,total Concentration 1.3 El 0 (7440-41-7) Mass 1.4 Cadmium,total ❑ � Concentration (7440-43-9) ✓ Mass 1.5 Chromium,total � Concentration 0 El (7440-47-3) ✓ Mass 1.6 Copper,total ❑ Concentration (7440-50-8) ✓ Mass 1.7 Lead,total Concentration (7439-92-1) ✓ Mass 1.8 Mercury,total 0Concentration 0 0 (7439-97-6) Mass 1.9 Nickel,total Concentration (7440-02-0) Mass Selenium,total Concentration 1.10 El El(7782-49-2) Mass 1.11 Silver,total Concentration 0 0 (7440-22-4) ✓ Mass EPA Form 3510-2C(Revised 3-19) Page 11 EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1 Presence or Absence (check one) Effluent Intake (optional) Pollutant/Parameter Testing Units Long-Term (and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number Present Absent Daily Monthly Daily of Term of Discharge Discharge Discharge Analyses Average Analyses (required) (if available) Value (if available) 1.12 Thallium,total ❑ 0 ❑ Concentration (7440-28-0) Mass 1.13 Zinc,total ❑ 0 0Concentration (7440-66-6) Mass 1.14 Cyanide,total ❑ ❑ 0Concentration (57-12-5) Mass Concentration 1.15 Phenols,total 0 0 ❑✓ Mass Section 2.Organic Toxic Pollutants(GCIMS Fraction—Volatile Compounds) 2.1 Acrolein El ❑ ❑ Concentration (107-02-8) Mass Acrylonitrile Concentration 2.2 (107-13-1) El El El Mass 2.3 Benzene ❑ ❑ ❑ Concentration (71-43-2) Mass 2.4 Bromoform 0 0 ❑ Concentration (75-25-2) Mass 2.5 Carbon tetrachloride ❑ ❑ Concentration (56-23-5) Mass 2.6 Chlorobenzene ❑ ❑ ❑ Concentration (108-90-7) Mass 2.7 Chlorodibromomethane ❑ ❑ ❑ Concentration (124-48-1) Mass Chloroethane 0 Concentration 2.8 (75-00-3) 0 Mass EPA Form 3510-2C(Revised 3-19) Page 12 EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1 Presence or Absence (check one) Effluent Intake (optional) Pollutant/Parameter Testing Units Long-Term (and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number Present Absent Daily Monthly of of Term Discharge Discharge DisDchaYge Analyses Average Analyses (required) (if available) Value (if available) 2.9 2-chloroethylvinyl ether Concentration (110-75-8) Mass 2.10 Chloroform(67-66-3) El ElConcentration Mass 2.11 Dichlorobromomethane ❑ Concentration (75-27-4) ✓ Mass 212 11-dichloroethane 0 Concentration (75-34-3) ✓ Mass 1,2-dichloroethane Concentration 2.13 (107-06-2) Mass 2.14 11-dichloroethylene ❑ Concentration (75-35-4) Mass 2.15 12-dichloropropane ❑ El El Concentration (78-87-5) Mass 2.16 1,3-dichloropropylene ID Concentration (542-75-6) ✓ Mass Ethylbenzene Concentration 2.17 El El El (100-41-4) Mass 2.18 Methyl bromide Concentration El 0 (74-83-9) ✓ Mass 2.19 Methyl chloride ❑ Concentration (74-87-3) ✓ Mass 2.20 Methylene chloride ElConcentration (75-09-2) Mass 2.21 1,1,2 2-tetrachloroethane ❑ 0 Concentration (79-34-5) Mass EPA Form 3510-2C(Revised 3-19) Page 13 EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))l Presence or Absence Intake (check one) Effluent (optional) Pollutant/Parameter Testing Units Long-Term (and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number Present Absent Daily Monthly Daily of Term of Dverag ischarge Discharge available) Discharge Analyses AValuee Analyses (if e) 2.22 Tetrachloroethylene Concentration (127-18-4) ✓ Mass 2.23 Toluene ❑ Concentration El El (108-88-3) Mass 1,2-trans-dichloroethylene Concentration 2.24 El 0 CI (156-60-5) Mass 2.25 1,1,1-trichloroethane ❑ 0 � Concentration (71-55-6) ✓ Mass 2.26 1,1,2-trichloroethane ❑ Concentration El El (79-00-5) Mass 2.27 Trichloroethylene El El El (79-01-6) Mass 2.28 Vinyl chloride ❑ Concentration (75-01-4) Mass Section 3.Organic Toxic Pollutants(GCIMS Fraction—Acid Compounds) 3.1 2-chlorophenol Concentration (95-57-8) ✓ Mass 3.2 2,4-dichlorophenol El El Concentration (120-83-2) Mass 2 4-dimethylphenol Concentration 3.3 (105-67-9) Mass 3.4 4,6-dinitro-o-cresol El El Concentration (534-52-1) ✓ Mass 3.5 2,4-dinitrophenol 0 El Concentration (51-28-5) ✓ Mass EPA Form 3510-2C(Revised 3-19) Page 14 EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 1 OMB No.2040-0004 an TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1 Presence or Absence (check one) Effluent Intake (optional) Pollutant/Parameter Testing Units Long-Term (and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number Present Absent Daily Monthly Daily of Term of D(eqh aruidge) Df available) Discharge Analyses AValuee Analyses r (if available) 3.6 2-nitrophenol 0 Concentration (88-75-5) Mass 3.7 4-nitrophenol Concentration (100-02-7) Mass 3.8 p-chloro-m-cresol Concentration (59-50-7) Mass 3.9 Pentachlorophenol Concentration (87-86-5) Mass Phenol Concentration 3.10 (108-95-2) Mass 3.11 2,4,6-trichlorophenol 0 Concentration (88-05-2) Mass Section 4.Organic Toxic Pollutants(GC/MS Fraction—Base(Neutral Compounds) 4.1 Acenaphthene Concentration 0 El El (83-32-9) Mass 4.2 Acenaphthylene El0 Concentration (208-96-8) Mass Anthracene Concentration 4.3 (120-12-7) Mass 4.4 Benzidine 0 Concentration 0 0 (92-87-5) Mass 4.5 Benzo(a)anthracene ❑ Concentration (56-55-3) Mass 4.6 Benzo(a)pyrene Concentration (50-32-8) Mass EPA Form 3510-2C(Revised 3-19) Page 15 t EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 i 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1 Presence or Absence (check one) Effluent Intake (optional) Pollutant/Parameter Testing Units Long-Term (and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number Present Absent Daily Monthly Dail of Term of Discharge Discharge Discharge Analyses AValuee Analyses (required) (if available) (if available) 4.7 3,4-benzofluoranthene 0Concentration EI El (205-99-2) Mass 4.8 Benzo(ghi)perylene Concentration (191-24-2) ✓ Mass 4.9 Benzo(k)fluoranthene Concentration (207-08-9) ✓ Mass Bis(2-chloroethoxy)methane 0 Concentration 4.10 El El (111-91-1) Mass 4.11 Bis(2-chloroethyl)ether 0Concentration 0 El (111-44-4) Mass 4.12 Bis(2-chloroisopropyl)ether Concentration (102-80-1) Mass 4.13 Bis(2-ethylhexyl)phthalate ❑ Concentration (117-81-7) ✓ Mass 4.14 4-bromophenyl phenyl ether ❑ 0 Concentration (101-55-3) Mass 4.15 Butyl benzyl phthalate ❑ Concentration (85-68-7) ✓ Mass 4.16 2-chloronaphthalene ❑ Concentration (91-58-7) ✓ Mass 4-chlorophenyl phenyl ether Concentration 4.17 (7005 72 3) � ❑ 0✓ Mass Chrysene Concentration 4.18 (218-01-9) 0 0 Mass 4.19 Dibenzo(a,h)anthracene ❑ Concentration (53-70-3) ✓ Mass EPA Form 3510-2C(Revised 3-19) Page 16 i EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1 Presence or Absence Intake (check one) Effluent (optional) Pollutant/Parameter Testing Units Long-Term (and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number Present Absent Daily Monthly Daily of Term of Discharge(required) Discharge available) Discharge Analyses Average Analyses ( 9 ) ( (if available) 4.20 1,2-dichlorobenzene ❑ ❑ ❑ Concentration 95-50-1 ( ) Mass 4.21 1 3-dichlorobenzene ❑ ❑ ❑ Concentration (541-73-1) Mass 4.22 1 4-dichlorobenzene ❑ ❑ ❑ Concentration (106-46-7) Mass 4.23 3,3-dichlorobenzidine ❑ ❑ ❑ Concentration (91-94-1) Mass Diethyl phthalate Concentration 4.24 0 0 ❑ (84-66-2) Mass Dimethyl phthalate Concentration 4.25 ❑ ❑ ❑✓ (131-11-3) Mass Di-nbty phthalate Di-n-butyl h Concentration 4.26 a ❑ ❑ ✓❑ (84-74-2) Mass 4.27 2 4-dinitrotoluene ❑ ❑ ❑ Concentration (121-14-2) Mass 4.28 2,6-dinitrotoluene ❑ ❑ ❑ Concentration (606-20-2) Mass 4.29 Di-n-octyl phthalate El ❑ ❑ Concentration (117-84-0) Mass 4.30 1,2-Diphenylhydrazine ❑ ❑ ❑ Concentration (as azobenzene)(122-66-7) Mass 4.31 Fluoranthene ❑ ❑ ❑ Concentration (206-44-0) Mass 4.32 Fluorene 0 0 ❑ Concentration (86-73-7) Mass EPA Form 3510-2C(Revised 3-19) Page 17 MIR EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1 Presence or Absence (check one) Effluent Intake (optional) Pollutant/Parameter Testing Units Long-Term (and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number Present Absent Daily Monthly Daily of Term of Discharge Discharge Discharge Analyses Average Analyses (required) (if available) (if available) Value 4.33 Hexachlorobenzene El0 Concentration El (118-74-1) Mass 4.34 Hexachlorobutadiene El0 Concentration (87-68-3) Mass 4.35 Hexachlorocyclopentadiene El0 Concentration El (77-47-4) Mass 4.36 Hexachloroethane 0 Concentration El El (67-72-1) Mass 4.37 Indeno(1,2,3-cd)pyrene � 0 Concentration (193-39-5) Mass 4.38 Isophorone 0 0 Concentration El (78-59-1) Mass 4.39 Naphthalene 0 El 0 Concentration (91-20-3) Mass 4.40 Nitrobenzene 0 Concentration 0 El (98-95-3) Mass 4.41 N-nitrosodimethylamine El El 0 Concentration (62-75-9) Mass 4.42 N-nitrosodi-n-propylamine El El 0 Concentration (621-64-7) Mass 4.43 N-nitrosodiphenylamine 0 Concentration El El (86-30-6) Mass 4.44 Phenanthrene El El 0 Concentration (85-01-8) Mass Pyrene Concentration 4.45 El El El (129-00-0) Mass EPA Form 3510-2C(Revised 3-19) Page 18 EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1 Presence or Absence (check one) Effluent Intake (optional) Pollutant/Parameter Testing Units Long-Term (and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number Present Absent Daily Monthly Daily of Tenn of D(reghed) itavalablle) Diarge Discharge scharge Analyses AValuee Analyses (if available) 1,2,4-trichlorobenzene Concentration 4.46 (120-82-1) ❑ El ❑ Mass Section 5.Organic Toxic Pollutants(GCIMS Fraction—Pesticides) Aldrin Concentration 5.1 (309-00-2) 0 0 ✓ Mass a-BHC Concentration 5.2 (319-84-6) El ❑ Mass R-BHC El Concentration 5.3 (319-85-7) El ❑ Mass y-BHC ✓ Concentration 5.4 (58 89 9) ❑ El El b-BHC ✓ Concentration 5.5 (319-86-8) El ❑ Mass 5.6 Chlordane ❑ ❑ Concentration (57-74-9) ✓ Mass . 5.7 4,4'-DDT ❑ ❑ ❑ Concentration (50-29-3) Mass 4,4'-DDE ✓ Concentration 5.8 El (72-55-9) Mass 5.9 4,4'-DDD ❑ ❑ ❑ Concentration (72-54-8) Mass 5.10 Dieldrin El ❑ Concentration (60-57-1) ✓ Mass 5.11 a-endosulfan ❑ ❑ ❑ Concentration (115-29-7) Mass EPA Form 3510-2C(Revised 3-19) Page 19 EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))1 Presence or Absence (check one) Effluent Intake (optional) Pollutant/Parameter Testing Units Long-Term (and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long Term Number Present Absent Daily Monthly Daily of of ischarge A D feq huge Dui ) f available) Discharge Analyses Value Analyses (if available) (3-endosulfan Concentration 5.12 (115-29-7) � 0 0 Mass 5.13 Endosulfan sulfate Concentration El El El (1031-07-8) Mass 5.14 Endrin Concentration (72-20-8) Mass Endrin aldehyde Concentration 5.15 (7421-93-4) Mass 5.16 Heptachlor Concentration El El El (76-44-8) Mass Heptachlor epoxide Concentration 5.17 (1024-57-3) 0 ❑ 0Mass PCB-1242 Concentration 5.18 (53469-21-9) 0 0 ✓❑ Mass PCB-1254 Concentration 5.19 (11097-69-1) 0 0 ElMass PCB-1221 Concentration 5.20 (11104-28-2) El 0 ❑ Mass PCB-1232 Concentration 5.21 (11141-16-5) ❑ El ❑ Mass PCB-1248 Concentration 5.22 (12672-29-6) El D 0 Mass PCB-1260 Concentration 5.23 (11096-82-5) El 0 0 Mass PCB-1016 Concentration 5.24 (12674-11-2) El ❑ ❑✓ Mass EPA Form 3510-2C(Revised 3-19) Page 20 EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE B.TOXIC METALS,CYANIDE,TOTAL PHENOLS,AND ORGANIC TOXIC POLLUTANTS(40 CFR 122.21(g)(7)(v))l Presence or Absence (check one) Effluent Intake (optional) Pollutant/Parameter Testing Units Long-Term (and CAS Number,if available) Required Believed Believed (specify) Maximum Maximum Average Number Long- Number Daily Monthly Term Present Absent Daily of of Discharge Discharge Discharge Analyses Average Analyses (required) (if available) Value (if available) Toxaphene Concentration 5.25 (8001-35-2) 0 0 ElMass 1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or required under 40 CFR chapter I,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3). EPA Form 3510-2C(Revised 3-19) Page 21 This page intentionally left blank. A EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))1 Presence or Absence (check one) Effluent Intake (Optional) Pollutant Units Maximum Long-Term Believed Believed (specify) Maximum DailyLong-Term Present Absent Discharge Monthly Average Daily Number of Average Number of Discharge Discharge Analyses Analyses (required) Value (if available) (if available) ❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall.You need not complete the"Presence or Absence"column of Table C for each pollutant. 1-1 Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall.You need not complete the"Presence or Absence"column of Table C for each pollutant. 1. Bromide ❑ ❑ Concentration (24959-67-9) Mass 2 Chlorine,total ❑ ❑ Concentration residual Mass Concentration color 77.0 1 3. Color ❑ 0 Mass NA El 0 Concentration MPN/100m1 12.2 1 4. Fecal coliform Mass NA 5 Fluoride ❑ ❑ Concentration (16984-48-8) Mass Concentration mg/L 0.099 1 6 Nitrate-nitrite 0 ❑ Mass lbs/day 0.537 Nitrogen,total Concentration mg/L 1.5 1 7. organic(as N) 11 ❑ Mass lbs/day 8.1 Concentration mg/L 5.0 1 8. Oil and grease ❑ ❑ Mass lbs/day 27.1 9 Phosphorus(as ❑ ❑ Concentration mg/L 0.36 1 P),total(7723-14-0) Mass lbs/day 1.95 10. Sulfate(as SO4) ❑ ❑✓ Concentration (14808-79-8) Mass Concentration 11. Sulfide(as S) 0 ❑✓ Mass EPA Form 3510-2C(Revised 3-19) Page 23 EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))1 Presence or Absence (check one) Effluent Intake (Optional) Pollutant Units Maximum Long-Term Believed Believed (specify) Maximum Daily Long-Term Present Absent Discharge Monthly Average Daily Number of Average Number of Discharge Discharge Analyses Analyses (required) Value (if available) (if available) 12. Sulfite(as S03) ❑ E✓ Concentration (14265-45-3) Mass Concentration 13. Surfactants El El Mass 14. Aluminum,totalI=1 El Concentration (7429-90-5) Mass 15. Barium,total 0 0 Concentration (7440-39-3) Mass 16. Boron,total 0 0 Concentration (7440-42-8) Mass 17 Cobalt,total 0 El Concentration (7440-48-4) Mass 15. Iron,total 0 0 Concentration (7439-89-6) Mass 19. Magnesium,total Concentration El 0 (7439-95A) Mass Molybdenum, Concentration 20. total 0 0 Mass (7439-98-7) 21 Manganese,total 0 0 Concentration (7439-96-5) Mass 22. Tin,total Concentration El 0 (7440-31-5) Mass 23 Titanium,total El Concentration (7440-32-6) Mass EPA Form 3510-2C(Revised 3-19) Page 24 I Ilia M EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE C.CERTAIN CONVENTIONAL AND NON CONVENTIONAL POLLUTANTS(40 CFR 122.21(g)(7)(vi))1 Presence or Absence (check one) Effluent Intake (Optional) Units Pollutant Maximum Long-Term Believed Believed (specify) Maximum Daily Long Term Present Absent Discharge Monthly Average Daily Number of Average Number of Discharge Discharge Analyses Analyses (required) Value (if available) (if available) 24. Radioactivity Concentration Alpha,total ❑ ❑✓ Mass Concentration Beta,total 0 ❑✓ — Mass Concentration Radium,total 0 ❑✓ Mass Concentration Radium 226,total 0 ❑✓ — _ Mass 1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or required under 40 CFR chapter I,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3). EPA Form 3510-2C(Revised 3-19) Page 25 nom __ FAWN WWI MEM allmor MOM _ i MEM 11111111E 1 This page intentionally left blank. y owow Ipm ma EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 12221(g)(7)(vii))1 Presence or Absence Pollutant (check one) Available Quantitative Data Believed Believed Reason Pollutant Believed Present in Discharge (specify units) Present Absent 1. Asbestos ❑ ❑✓ 2. Acetaldehyde 0 ❑✓ 3. Allyl alcohol ❑ ❑✓ 4. Allyl chloride 0 ❑✓ 5. Amyl acetate ❑ ❑✓ 6. Aniline 0 ❑✓ 7. Benzonitrile 0 ❑✓ 8. Benzyl chloride 0 ❑✓ 9. Butyl acetate ❑ ❑✓ 10. Butylamine ❑ 0 11. Captan ❑ 0 12. Carbaryl ❑ ❑✓ 13. Carbofuran 0 0 14. Carbon disulfide ❑ ❑✓ 15. Chlorpyrifos ❑ ❑✓ 16. Coumaphos ❑ 0 17. Cresol ❑ ❑✓ 18. Crotonaldehyde ❑ ❑✓ 19. Cyclohexane ❑ ❑✓ EPA Form 3510-2C(Revised 3-19) Page 27 NM MI N NM M MB aft EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 12221(g)(7)(vii))1 Presence or Absence Pollutant (check one) Available Quantitative Data Believed Believed Reason Pollutant Believed Present in Discharge (specify units) Present Absent 20. 2,4-D(2,4-dichlorophenoxyacetic acid) ❑ ❑✓ 21. Diazinon ❑ ❑✓ 22. Dicamba ❑ ❑✓ 23. Dichlobenil 0 0 24. Dichlone 0 0 25. 2,2-dichloropropionic acid 0 0 26. Dichlorvos 0 0 27. Diethyl amine 0 0 28. Dimethyl amine 0 0 29. Dintrobenzene 0 0 30. Diquat 0 0 31. Disulfoton 0 ❑✓ 32. Diuron 0 0 33. Epichlorohydrin 0 ❑✓ 34. Ethion 0 0 35. Ethylene diamine 0 0 36. Ethylene dibromide 0 0 37. Formaldehyde ❑ 0 38. Furfural 0 0 EPA Form 3510-2C(Revised 3-19) Page 28 NM M EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 • 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040 0004 TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 122.21(g)(7)(vii))1 Presence or Absence Pollutant (check one) Available Quantitative Data Believed Believed Reason Pollutant Believed Present in Discharge (specify units) Present Absent 39. Guthion ❑ ❑✓ 40. Isoprene ❑ ❑✓ 41. Isopropanolamine ❑ ❑✓ 42. Kelthane ❑ ❑✓ 43. Kepone ❑ ❑✓ 44. Malathion ❑ ❑✓ 45. Mercaptodimethur ❑ ❑✓ 46. Methoxychlor ❑ ❑✓ 47. Methyl mercaptan ❑ ✓❑ 48. Methyl methacrylate ❑ ❑✓ 49. Methyl parathion ❑ ❑✓ 50. Mevinphos ❑ ❑✓ 51. Mexacarbate ❑ ❑✓ 52. Monoethyl amine 0 ❑✓ 53. Monomethyl amine 0 ❑✓ 54. Naled ❑ ❑✓ 55. Naphthenic acid ❑ ❑✓ 56. Nitrotoluene ❑ ❑✓ 57. Parathion 0 ❑✓ EPA Form 3510-2C(Revised 3-19) Page 29 EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 12221(g)(7)(vii))l Presence or Absence Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data Believed Believed (specify units) Present Absent 58. Phenolsulfonate 0 ❑✓ 59. Phosgene 0 ❑✓ 60. Propargite 0 ❑✓ 61. Propylene oxide 0 ❑✓ 62. Pyrethrins 0 0 63. Quinoline ❑ ❑✓ 64. Resorcinol ❑ ❑✓ 65. Strontium ❑ ❑✓ 66. Strychnine ❑ ❑✓ 67. Styrene 0 ❑✓ 68. 2,4 5-T(2,4,5-trichlorophenoxyacetic ❑ ❑✓ acid) 69. TDE(tetrachlorodiphenyl ethane) ❑ ❑✓ 70. 2,4,5-TP[2-(2,4,5-trichlorophenoxy) ❑ ❑✓ propanoic acid] 71. Trichlorofon 0 ❑✓ 72. Triethanolamine 0 ❑✓ 73. Triethylamine 0 ❑✓ 74. Trimethylamine 0 ❑✓ 75. Uranium 0 ❑✓ 76. Vanadium 0 ❑✓ EPA Form 3510-2C(Revised 3-19) Page 30 EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE D.CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS(40 CFR 12221(g)(7)(vii))1 Presence or Absence Pollutant (check one) Reason Pollutant Believed Present in Discharge Available Quantitative Data Believed Believed (specify units) Present Absent 77. Vinyl acetate ❑ ❑✓ 78. Xylene ❑ ❑✓ 79. Xylenol ❑ ❑✓ 80. Zirconium ❑ ❑✓ 1 Sampling shall be conducted according to sufficiently sensitive test procedures(i.e.,methods)approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or required under 40 CFR chapter I,subchapter N or 0.See instructions and 40 CFR 122.21(e)(3). EPA Form 3510-2C(Revised 3-19) Page 31 II I i i This page intentionally left blank. EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19 110018833994 NC0085936 Jerry G.Williams&Sons,Inc. 001 OMB No.2040-0004 TABLE E.2,3,7,8 TETRACHLORODIBENZO P DIOXIN(2,3,7,8 TCDD)(40 CFR 122.21(g)(7)(viii)) TCDD Presence or Congeners Absence Pollutant Used or (check one) Results of Screening Procedure Manufactured Believed Believed Present Absent 2,3,7,8-TCDD 0 0 0 EPA Form 3510-2C(Revised 3-19) Page 33 'NV • .. ,v • a 7:71 u fis 1 IS$ '.. )v" ,_ ', Vvg:.•. , ,,,. ,,,s, \— _ ✓ 13 i• ,' Courthov • PO Ce! '7f. I° t 4 Smit• 2 . ',— _ / J�. ' ,. f ., �. a • } i. - • Q * `1!; !t\\ ' '' ! pi, S M ,i`? s its om - � • •.'I ; K F I E'• '' '' ,. tf 1 r4EVS 0 ' ,,:-.'.: -mts;,:.„. ' " 1 io.,.' . A'S ' .. %VAMP -- : "-, /asp , _ ,' A, i - /i"r ‘t, -':7 # 4,/ -• 1•741rgAtivdifiti,t4;41,3i'r ..,...,,v, ...4CII. s . i ., . .,._. - ,,,,\., 4To iiiipp". .4....,01.7 -Ap ._,. y,/..-- 4e,4 F *:.11EIPPir" 41* 'Q. r7 z Approximate 1 - '• / �4 — - ''...-k.....'—.7.--'1‘ L: :-.8404,10.•• / 1110.,..;„,.."-.- .• n Lit5,1 0,144 bc . 6, .- 'z.t�� ' �; . ' 7 //174. , ' ' . ..._ -„,:/fi 'A, i#0,10— 0, i- ....A - y., ' . -- ..tilite \ *V - -. /-',t1"-,--\,\. 1 -.--- „.1 ' (- t) --- ' ii: . 1 • ` lip/ om C,.coe.a (c---- cur . t : .1- / \ ) _:: i Neuse River/l%. re: f . %�- 0$4.- tu.;((laws southeast! {' \ ` ' ▪ Ii ,; \ '\ - 1;die: - , / e.e.' 1—, i ) (vs) -gdOG •\ ( A.,,, 1,•; -Copyyrigh`Y2.13tsiaho ar eogftaphi,Souety.i-cubed Jerry G Williams & Sons, Inc. N 1.g y , NPDES Permit NC0085936 524 Brogden Road, Smithfield 27577 "room Receiving Stream:U I to Neuse Riser Stream Segment:27-(41.7) Stream Class:WS-V;NSW 35.4931°N, -78.3528°W River Basin:Neuse Sub-Basin 0:03.04-02 5c'M i NC Grid:E25SE Count):Johnston IlUC:030101040602 1:24.000 USGS Quad:Selma.NC • • Jerry G. Williams & Sons Inc. -'' wv ,'414Sa , .;: ,,,,,,,,,,,,..„ .. ... .. . ..:4,......47.,,... 4,.. ..,.. , .. , 4140 �4 . 1:.', ;/• / . • d tt • ir ' del,: - t .. .� i -® • 1,- ..e '/ •k* sr A , 404-\ y - •Ty \ o.-„ n} -.i1-" • • I.. tKd ...v'. b . . . . . , j Y ,e': -, 4/ , ir / . ; , 4,.,,.. 0 , , ...,, r, 4, ,, ,, ''‘..,,,,, / ., - ' - • ' ' • ' 4,-..4'.•› " '--<-'•-0,„:,4..- ''..4-;:,...,.4.....:....,..„7,7,-,,„..*:,..„:-,, ',...„..:-, 41's • 4 r . ,. • 4 ' „tAl,:,_/. .,;,..., - / / �� ./,/ �.t,1 r t . ,;"vim V. - f r 4 , • Wet Dec , mg ;' • ,N. y • ff ,' t ` l _ J/ ' r=te r r •\N. .....40 Q•= • bra • , . �iF 4 : //, /,,, M s Outfall 001 ;3 2 548' 3OHNVON u * ** DISCLAIMER OUN a. Johnston County assumes no legal responsibility for the information represented here. NO RTH•CAROL[NA � F ( _ 4 *F'I!! W74Y7Urc QIl s_r . o I P ♦ .b 4roo �► ifil 5/ // de IL,Aw.", ••# *slum, - ** Pin ., <c,44, li,,4COIIpIPP-ifoe :% ',, 1.1P.°'-, , >if , w N Nw * icy y �7.,® � �I , Ak & 4 ::e, s,z. # 110,1,13:) i '‘f/r \'' 1 i. 4V* 1 'J / / 4 Ili a "; / 4.,,,,,,,-, . (41 / 'N '‘' tir ,' A‘.. Al& ,. \I all 1111111 IIII '"111 A / 4%i/oc, AO, it„* ' # 4,K4I r k'''' mem 1 40, ______, ., ,4p. ,10, i4pse,,,Av. ;//, : „ss<tit, / 79, Iliv :, 0 d fi \\84-41:A•17.--- ippA :iv_ _ _ Jisil ....47 • W4%% 1/ !17 A / 445) i \,,,loiorz:, 4 ------Ziii 4Aeht,44,•`..k. � 4 („--- 4 ter► � �.� , - -, - .74, mir.AlPi .,. . ie kik .r►Allil frAid • k..,„ _ V, , 0 \ cr4rtAll7 4111 'I'l ivt. ir/41/1/..4144,44, 14, ..._. d° 6 *Th 44-4 1 V/: j I MA Pal I rgi re.%• Illiki 1 N .=QP /4017* > -� M+�R=TIN=LUTH�ER I � S0N " , W011ik\ / //' ' frI NtiF , ./ , „ ir)7' fr". 1! a h. is.,. \.. i Y�R� 1 \ + .9� ci , / 411I \, JERRY G. WILLIAMS& SONS, INC.-PROPERTY BOUNDARY Scale: 1:4022 - 1 in.=335.14 feet - 1-0- Johnston County GIS \ 524 BROGDON ROAD, SMITHFIELD, NORTH CAROLINA 27577 (The scale is only accurate when printed landscape on a 11 x 17 size sheet with no page scaling.) April 18,2023 Pace Analytical Services,LLC aceAnalytical 6701 ConferenceDrive07 Raleigh,NC 27607 www.pacelabs.com (919)834-4984 Page 1 of 2 Laboratory Report Jerry G. Williams Report Date: 04/18/2023 Jerry G. Williams & Sons Date Received: 04/05/2023 P.O. Box 2430 Smithfield, NC 27577 Project: Waste Water Pace Project No.:92660637 Sample: ww Lab ID: 92660637001 Collected: 04/05/23 08:30 Matrix: Water Method Parameters Results Units Report Limit Analyzed Qualifiers SM 2120E Color ADMI- Color,ADMI 79.0 units 25.0 04/06/23 13:37 1993 SM 2120E Color ADMI- Adjusted Color,ADMI 77.0 units 25.0 04/06/23 13:37 1993 SM 2120E Color ADMI- pH 8.0 units 1.0 04/06/23 13:37 1993 SM 2120E Color ADMI- Adjusted pH,ADMI 7.6 units 1.0 04/06/23 13:37 1993 SM 2540D-2015 Total Suspended Solids ND mg/L 3.8 04/07/23 11:42 SM 5210B-2011 BOD,5 day 9.5 mg/L 2.0 04/11/23 13:15 EPA 1664B Oil and Grease ND mg/L 5.0 04/14/23 14:20 Colilert-18 Fecal Coliforms 12.2 MPN/100mL 1.0 04/06/23 10:45 TKN-NH3 Calculation Total Organic Nitrogen 1.5 mg/L 0.50 04/18/23 06:48 EPA 350.1 Rev 2.0 1993 Nitrogen,Ammonia ND mg/L 0.10 04/13/23 11:39 EPA 351.2 Rev 2.0 1993 Nitrogen,Kjeldahl,Total 1.6 mg/L 0.50 04/18/23 03:48 EPA 353.2 Rev 2.0 1993 Nitrogen,NO2 plus NO3 0.099 mg/L 0.040 04/14/23 11:51 EPA 365.1 Rev 2.0 1993 Phosphorus 0.36 mg/L 0.050 04/12/23 14:39 SM 5220D-2011 Chemical Oxygen Demand 61.4 mg/L 25.0 04/08/23 16:45 SM 531 013-2 01 4 Total Organic Carbon 15.4 mg/L 1.0 04/12/23 18:34 Sample: SET SOLIDS Lab ID: 92660637002 Collected: 04/05/23 08:30 Matrix: Water Method Parameters Results Units Report Limit Analyzed Qualifiers SM 2540E-2015 Total Settleable Solids NO mUUhr 0.10 04/06/23 14:47 ` Reviewed by: vim`; Terri Page (336)623-8921 terri.page@pacelabs.com Pace Analytical Services Raleigh 4915 Waters Edge Dr.#120,Raleigh,NC 27606 North Carolina Drinking Water Certification#:37731 North Carolina Wastewater Certification#:67 Pace Analytical Services Charlotte South Carolina Laboratory ID:99006 South Carolina Certification#:99006001 9800 Kincey Ave.Ste 100,Huntersville,NC 28078 South Carolina Drinking Water Cert.#:99006003 North Carolina Drinking Water Certification#:37706 Florida/NELAP Certification#:E87627 North Carolina Field Services Certification#:5342 Kentucky UST Certification#:84 North Carolina Wastewater Certification#:12 Louisiana DoH Drinking Water#:LA029 South Carolina Laboratory ID:99006 VirginiaNELAP Certification#:460221 Pace Analytical Services Asheville 2225 Riverside Drive,Asheville,NC 28804 Florida/NELAP Certification#:E87648 Page 1 of 4 Analytical i LLC Pace yt cal Services,t ace Analytical 6701 Conference Drive Raleigh,NC 27607 www.pacelabs.com (919)834-4984 Page 2 of 2 Pace Analytical Services Asheville North Carolina Drinking Water Certification#:37712 South Carolina Certification#:99030001 North Carolina Wastewater Certification#:40 VirginiaNELAP Certification#:460222 South Carolina Laboratory ID:99030 Pace Analytical Services Eden 205 East Meadow Road Suite A,Eden,NC 27288 North Carolina Wastewater Certification#:633 North Carolina Drinking Water Certification#:37738 VirginiaNELAP Certification#:460025 Page 2 of 4 a , 16FA tiid0 L': _'t.'RIi 1.',f ''ilIliIg'.:iH,11.: .,--- i ' -s 1 p — A cY F, 4{oEabed - o N b d 1 g ° N a � ° a ASV •TT , $ is S_n A x rn 0'1 r2. at,i ark w I.. $,R m 3 ft i:rS � 1 "}i' ii412111111 a a I. C. ?r z P o a m V :. }Y O � � a 111111 ATRIX CODE (t: ccdnkR)AMPLE TYPE (GG9 GC1i111111111111I � �W• !3 n s 7,�iuiuiuisiir � It! IIIIIIIUhILL:C.. ... — '- -- y , _F, = 71 , N4 L �� .. .�-.-..-. umMOFCCNTR4ER3 k : -Z 5 cp a � ;. vi UIIIIIIIIIIIIIE t:5-.. itt o f g 2• a 0 o ., , a I. NaOH a 0 t"-- ylu L Ne2S203 HI g`• Methanol i, th i — . • I. _ .Ila flame.'iAiiiiJ1�I+�LI:.I :ii: B a a jgi800 5 day .. = d co 1' ,$ COD Chertical Oxygen Dem ai x N , C P. m CD N Will :F•s:1! Fecal CaG " E n �F74 2120E Color ADM! a F 0 f, TOC(total crgaeccarbon) m v n N@rate+Nitn'b by 353.2 .,1 ' 7 a J=' Sortable Scas by SM254CF r ill TSS Total Suspended Solids rl (D_ O 1. ! Bi "I DI end Grease W 1664 i ;•�h: Total Phosphorus iE Ig It q Total Organic Nitrogen E J • ' TEMP in C ' :� Residual CNorine(YIN) •i yj I I'-l N 111� 2 - 1 cn Received an Ica(YIN) ' '1};tf. A _ ,ii v I., ., Tit f ® I. U _ Custody Sealed ♦ '^• l� t•�;�'r i.� a (YIN) II '�J• l'I /!1 1 , W II Sa(Yrmples Intact r ( lA;�. iy�,F� I S !� ip f. !I;l;"JIDS• ICI ys 1 DC#_Title: ENV-FRM-HUN1-0083 v01_Sample Condition Upon Receipt Ce' umrc¢irr;cu Effective Date:05/12/2022 Laboratory receiving samples; Asheville❑ Eden❑ Greenwood❑ Huntersville❑ Raleigh Mechanicsville❑ Atlanta] Kernersville❑ Sample Condition Client Name: Upon Receipt Project 0: ) rio Courier: F d Ex ❑UPS USPS Client ❑ Commercial ace ie"'Pi C. kvi❑Other: Custody Seal Present? ❑//Yes ;o Seals Intact? ❑yes `�'" ii Date/Initials Person Examining Contents:# Z,3—agti Packing Material: 0 Bubble Wrap ❑Bubble Bags Xne ❑ Other Biological Tissue Ffr zen? Thermometer: ❑Yes Cho N/A ❑ IR Gun ID: /7020S Type of Ice: et ❑Blue ❑None Correction Factor: Cooler Temp: �' Add/Subtract('C) G Temp should be above freezing to 6'C Samples out of temp criteria.Samples on ice,cooling process Cooler Temp Corrected (°C). — has begun USDA Regulated Soil( a7N/A,water sample) Did samples originate in a rantine zone within the United States:CA,NY,or Sc Did samples originate from a foreign source(internatio ally, (check maps)?❑Yes No including Hawaii and Puerto Rico)?(]Yes PPS Comments/Discrepancy: Chain of Custody Present? s ❑No N/A 1. Samples Arrived within HeNS rime? s—D'No-9N/A——2. Short Hold Time Analysis(<72 hr.)? s D No ❑N/A 3. Rush Turn Around Time Requested? D Yes Jo ❑N/A 4. Sufficient Volume? „es ❑No ❑N/A 5. Correct Containers Used? yps No ❑N/A 6. -Pace Containers Used? �—,/es ❑No ON/A Containers Intact? es No ❑N/A 7. Dissolved analysis:Samples Field Filtered? ❑Yes ❑Na reWA 8. Sample Labels Match COC? ��( Yes D No ❑N/A 9. -Includes Date/Time/ID/Analysis Matrix: i/ Headspace in VOA Vials(>5-6mm)? yKes ❑No rj/A 10. Trip Blank Present? ❑Yes No N A 11. Trip Blank Custody Seals Present? Oyes ONoA COMMENTS/SAMPLE DISCREPANCY S-R$ otlZ Field Data Required? ❑Yes ❑No ge ds rice I?? L//A/ - - i 5- /pe ` 7Licr7 5 gym' Lot ID of split containers: CLIENT NOTIFICATION/RESOLUTION Person contacted: — Date/Time: • Project Manager SCURF Review: Date: Project Manager SRF Review: Date: � Page 4 oil;4 tmourav In- AaR1d Dana I nt