HomeMy WebLinkAboutWQ0035784_Monitoring - 11-2023_20231220Monitoring Report Submittal
Permit Number#*
Name of Facility:*
Month: * November
Report Information
Type *
GW-59
Confirmation Email Address:
Name of Submitter: *
Signature:
Date of submittal:
Initial Review
WQ0035784
THE COTTAGES OF BOONE
Year:* 2023
Upload Document*
11-2023 COB GW-59.pdf 2.93MB
PDF Only
Please upload one PDF containing all applicable monitoring reports
(i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59).
mmills@envirolinkinc.com
Envirolink, Inc.
Reviewer: Wanda.Gerald
12/20/2023
This will be filled in automatically
Is the project number correct?* WQ0035784
Is the monitoring report accepted?* Yes No
Regional Office* Winston-Salem
Reviewer: _anonymous
Review Date: 1/3/2024
SUBMIT FORM ON YELLOW PAPER ONLY
• •
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
•
• . •
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 4/1/2026
Facility Name: THE COTTAGES OF BOONE WWTP
Non -Discharge W00035784 UIC
Permit Name (if different):
NPDES Other
Facility Address: 615 FALLVIEW LN
TYPE OF PERMITTED OPERATION BEING MONITORED
BOONE NC
28607 County WATAUGA
❑ Lagoon ❑ Remediation: Infiltration Gallery
0 Spray Field ❑ Remediation:
Contact Person: David Rogers
Telephone#: 828-734-1314
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: MW1
No. of wells to be sampled: 3
❑ Water Source Heat Pump ❑ Other:
(from Permit)
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): MW1
Date sample collected: 11/28/2023
FIELD ANALYSES:
WAS
Well Depth: 20 ft.
Well Diameter: 24 in.
pH 00400: N/A units Temp. 000lo: NSA °C
DRY at
Depth to Water Level 82546: 0 ft. below measuring point Screened Interval: 10 ft.
to 20
ft. Spec. Cond. 00094: µMhos
time of
sampling,
Measuring Point is 2 ft. above land surface
Relative M.P. Elevation:
ft.
Odor 00085: None
check
Volume of water pumped/bailed before sampling:
0
gallons
Appearance None
here:
Samples for metals were collected unfiltered: ❑ YES
0 NO and field acidified: ❑ YES
0 NO
LABORATORY INFORMATION
Date sample analyzed: 11/28/2023
Laboratory Name: Statesville Analytical
Certification No. 440
PARAMETERS NOTE: Values should reflect
dissolved
and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615
mg/L Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616
/100mL
Nitrate (NO3) as N 00620
mg/L Zn - Zinc 01092 mg/L
Coliform: MF Total 31504
/100mL
Phosphorus: Total as P 00665
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L Other (Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300
mg/L
Al - Aluminum oilo5
mg/L
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 00680
mg/L
Ca - Calcium 00916
mg/L
Chloride 00940
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552
mg/L
Cu - Copper 01042
mg/L ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730
ug/L
Fe - Iron 01045
ug/L
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 00095
µMhos
K - Potassium 00937
mg/L VOC 7873 method #
Total Ammonia 00610
mg/L
Mg - Magnesium 00927
mg/L method #
(Ammonia Nitrogen; NH3 as N; Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L
method #
TKN as N 00625
mg/L
Ni - Nickel 01067
ug/L
method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%
MADELYN MILLS, ENVIROLINK, INC.
Madelyn Mills 12/20/2023
Permittee (or Authorized Aqent) Name and Title - Please print or type
GW-59 Rev.06-07-2018
Siqnature of Permittee (or Authorized Aqent)
(Date)
SUBMIT FORM ON YELLOW PAPER ONLY
• •
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
• • .
•
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 4/1/2026
Facility Name: THE COTTAGES OF BOONE WWTP
Non -Discharge W00035784 UIC
Permit Name (if different):
NPDES Other
Facility Address: 615 FALLVIEW LN
TYPE OF PERMITTED OPERATION BEING MONITORED
BOONE NC
28607 County WATAUGA
❑ Lagoon ❑ Remediation: Infiltration Gallery
0 Spray Field ❑ Remediation:
Contact Person: David Rogers
Telephone#: 828-734-1314
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: MW2
No. of wells to be sampled: 3
❑ Water Source Heat Pump ❑ Other:
(from Permit)
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): MW2
Date sample collected: 11/28/2023
FIELD ANALYSES:
WAS
Well Depth: 19 ft.
Well Diameter: 24 in.
pH 00400: 6.36 units Temp. 000lo: 7.1 °C
DRY at
Depth to Water Level 82546: 13 ft. below measuring point Screened Interval: 5 ft. to
19 ft.
Spec. Cond. 00094: µMhos
time of
sampling,
Measuring Point is 2 ft. above land surface
Relative M.P. Elevation: ft.
Odor 00085: None
check
Volume of water pumped/bailed before sampling:
1
gallons
Appearance Clear
here:❑
Samples for metals were collected unfiltered: ❑ YES
0 NO and field acidified: ❑ YES 0 NO
LABORATORY INFORMATION
Date sample analyzed: 11/28/2023
Laboratory Name: Statesville Analytical
Certification No. 440
PARAMETERS NOTE: Values should reflect
dissolved
and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615
mg/L
Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616 10
/100mL
Nitrate (NOA as N 00620 0.547
mg/L
Zn - Zinc 01092 mg/L
Coliform: MF Total 31504
/100mL
Phosphorus: Total as P 00665 2.55
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L
Other (Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300 101
mg/L
Al - Aluminum oilo5
mg/L
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 0068o 3.06
mg/L
Ca - Calcium 00916
mg/L
Chloride 0094o 28.9
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552
mg/L
Cu - Copper 01042
mg/L
ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730
ug/L
Fe - Iron 01045
ug/L
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑■ Yes (1) ❑ No (0)
Specific Conductance 00095
µMhos
K - Potassium 00937
mg/L
VOC 7873 , method #
Total Ammonia 00610 <0.1
mg/L
Mg - Magnesium 00927
mg/L
VOC 8260 method # 8260
(Ammonia Nitrogen; NH3 as N; Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L
method #
TKN as N 00625 3.81
mg/L
Ni - Nickel 01067
ug/L
method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%
MADELYN MILLS, ENVIROLINK, INC.
Permittee (or Authorized Aqent) Name and Title - Please print or type
Digitally signed by: Madelyn Mills
DN: CN = Madelyn Mills email = mmills@envimlinkinc.com C = US O =
Madelyn I S Envirolink, Inc. OU = Compliance Coordinator 12/20/2023
Siqnature of Permittee (or Authorized Aqent) (Date)
GW-59 Rev.06-07-2018
SUBMIT FORM ON YELLOW PAPER ONLY
• •
DEPARTMENT OF ENVIRONMENTAL QUALITY - DIV. OF WATER RESOURCES
GROUNDWATER QUALITY MONITORING:
INFORMATION PROCESSING UNIT
COMPLIANCE REPORT FORM
•
• . •
1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617
FACILITY INFORMATION
Please Print Clearly or Type
PERMIT Number: Expiration Date: 4/1/2026
Facility Name: THE COTTAGES OF BOONE WWTP
Non -Discharge W00035784 UIC
Permit Name (if different):
NPDES Other
Facility Address: 615 FALLVIEW LN
TYPE OF PERMITTED OPERATION BEING MONITORED
BOONE NC
28607 County WATAUGA
❑ Lagoon ❑ Remediation: Infiltration Gallery
❑■ Spray Field ❑ Remediation:
Contact Person: David Rogers
Telephone#: 828-734-1314
❑ Rotary Distributor ❑ Land Application of Sludge
Well Location/Site Name: MW3
No. of wells to be sampled: 3
❑ Water Source Heat Pump ❑ Other:
(from Permit)
SAMPLING INFORMATION
If WELL
WELL ID NUMBER (from Permit): MW3
Date sample collected: 11/28/2023
FIELD ANALYSES:
WAS
Well Depth: 26 ft.
Well Diameter: 24 in.
pH 00400: N/A units Temp. 000lo: NSA °C
DRY at
Depth to Water Level 82546: 0 ft. below measuring point Screened Interval: 16 ft.
to 26 ft.
Spec. Cond. 00094: µMhos
time of
sampling,
Measuring Point is 2 ft. above land surface
Relative M.P. Elevation:
ft.
Odor 00085: None
check
Volume of water pumped/bailed before sampling:
0
gallons
Appearance None
here:
Samples for metals were collected unfiltered: ❑ YES
0 NO and field acidified: ❑ YES
0 NO
LABORATORY INFORMATION
Date sample analyzed: 11/28/2023
Laboratory Name: Statesville Analytical
Certification No. 440
PARAMETERS NOTE: Values should reflect
dissolved
and colloidal concentrations.
COD 00335
mg/L
Nitrite (NO2) as N 00615
mg/L
Pb - Lead 01051 ug/L
Coliform: MF Fecal 31616
/100mL
Nitrate (NOA as N 00620
mg/L
Zn - Zinc 01092 mg/L
Coliform: MF Total 31504
/100mL
Phosphorus: Total as P 00665
mg/L
(Note: Use MPN method for highly turbid samples)
Orthophosphate 70507
mg/L
Other (Specify Compounds and Concentration Units):
Dissolved Solids:Total 70300
mg/L
Al - Aluminum oilo5
mg/L
pH (Lab) 00403
units
Ba - Barium 01007
ug/L
TOC 00680
mg/L
Ca - Calcium 00916
mg/L
Chloride 00940
mg/L
Cd - Cadmium 01027
ug/L
Arsenic 01002
ug/L
Chromium: Total 01034
ug/L
Grease and Oils 00552
mg/L
Cu - Copper 01042
mg/L
ORGANICS: (by GC, GC/MS, HPLC)
Phenol 32730
ug/L
Fe - Iron 01045
ug/L
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate 00945
mg/L
Hg - Mercury 71900
ug/L
Lab Report Attached? ❑ Yes (1) ❑ No (0)
Specific Conductance 00095
µMhos
K - Potassium 00937
mg/L
VOC 7873 method #
Total Ammonia 00610
mg/L
Mg - Magnesium 00927
mg/L
method #
(Ammonia Nitrogen; NH3 as N; Ammonia Nitrogen, Total)
Mn - Manganese 01055
ug/L
method #
TKN as N 00625
mg/L
Ni - Nickel 01067
ug/L
method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal%
MADELYN MILLS, ENVIROLINK, INC.
Permittee (or Authorized Aqent) Name and Title - Please print or type
Digitally signed by: Madelyn Mills
Madelyn Mills En CN =Madelyn Mills email = Coor@envirolinkinc com C = US 0 =
Date:02 Inc. OU =Compliance Coordinator 12/20/2023
Date: 2023.12.20 10:39:00-05'00'
Siqnature of Permittee (or Authorized Aqent) (Date)
GW-59 Rev.06-07-2018
Analytical Results STATESVILLE
ANALYTICAL
Cottages of Boone- Envirolink
615 Fallview Lane
Boone, NC 28607
Receive Date: 11/28/2023
Reported: 12/14/2023
For: Monitoring Wells
Comments:
Sample Number Parameter Sample ID Result
231128-30-01
231128-30-01
231128-30-01
231128-30-01
231128-30-01
231128-30-01
231128-30-01
231128-30-01
231128-30-01
Ammonia Nitrogen
MW2
Chloride
MW2
Fecal Coliforms
MW2
Nitrate
MW2
T. Phosphorous
TKN
TOC
Total Dissolved
Solids
VOC
Respectfully submitted,
Melissa Myers
NC Cert #440,
NCDW Cert #37755,
EPA #NC00909
MW2
MW2
MW2
MW2
Unit Method Analyzed Analyst
<0.1
mg/L
SM4500NH3C-2011
12/04/2023
LE
28.9
mg/L
SM4500CIC-2011
11/29/2023
MD
10
CFU100 ML
SM9222D-2015
11/28/2023
MD
0.547
mg/L
M4500
12/01/2023
CL
NO3F+NO2
SM4500-NO3-F2016
2.55
mg/L
SM450OPE-2011
12/01/2023
CL
3.81
mg/L
SM4500NorgB-2011
11/30/2023
LE
3.06
mg/L
SM5310B
12/06/2023
MT
101
mg/L
SM 2540 C-2015
11 /29/2023
MD
MW2 See Attached SM6230D 12/04/2023 MT
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 6
Condition of Receipt
Sample Number 231128-30-01 Temp on Arrival: 4.0
Parameter Schedule: Total Dissolved Solids
Received on Ice
Parameter Schedule: Fecal Coliforms
Sodium Thiosulfate Received on Ice
Chemicals in containers, lab
pH on Arrival: <2 Parameter Schedule: T. Phosphorous
Sulfuric Acid Received on Ice
Chemicals in containers, lab
pH on Arrival: <2 Parameter Schedule: TKN
Sulfuric Acid Received on Ice
Chemicals in containers, lab
pH on Arrival: <2 Parameter Schedule: Ammonia Nitrogen
Sulfuric Acid Received on Ice
Chemicals in containers, lab
pH on Arrival: <2 Parameter Schedule: Nitrate
Sulfuric Acid Received on Ice
Chemicals in containers, lab
Parameter Schedule: Chloride
Received on Ice
pH on Arrival: <2 Parameter Schedule: VOC
Ascorbic Acid Received on Ice
Chemicals in containers, lab
pH on Arrival: <2 Parameter Schedule: TOC
Phosphoric Acid Received on Ice
Chemicals in containers, lab
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 2 of 6
Client:
a
STATESVILLE
"r ANALYTICAL
Address:
sr/ L
�y 122 Court street • P.O. Box 228
�Stalcsvillc, NC 28687
(704) 872-4697
i Chain
Contact Person: ' Phone # FAX#
kaLgr ��
of
Custody Record
PO # Requisitioned by: (Time Date)
Customer
Sam p la IN
Lab -ID N
Time Sampled
(Grab Only)
Dale Sampled
(Grab Only)
Matrix
§k w ww
I'aramrlcrs mquc%1 J for analysis
vJ
6 1 2 30-v
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sow
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Relinquished by: I-�d
Timeam,Date
Sampled by:
Received by: �i'�L�
D
, i7wt��"'
Time am6"Date _,Zb-1�; 3
Transported by: —%�-
Relinquished by:
Time / S a s am,/�!m Date ��
,0�r/
Holding times met:
Received by:
Time 15 Z8 am, pm Date / // -Z 7-3
Compliance work:
Composite Sampling
#1:
Time begin am, pm Date _/_/_
Non-compliance work:
Time end am, pm Date _/_/_
Lab Comments: Samples Transported On Ice:
Ye S
Composite Sampling
#2:
Time begin am, pm Date
Time end am, pm Date _/_/_
Initials: N
rn
N O
cM
00
o a
I"
00
00
N
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N
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Contact: C. Little
Client: Statesville Analytical
122 Court St
Statesville, NC 28677
Meritech, Inc.
Environmental Laboratory
Laboratory Certification No.165
Meritech Work Order # 12012330 Sample: 231128-30-01 Grab
Report Date: 12/13/2023
Date Sample Rcvd: 12/1/2023
11/28/23
Parameters Results Analysis Date Reporting Limi Method
TOC 3.06 mg/L 12/6/23 1.00 mg/L SM 5310C
Meritech Work Order # 12012331 Sample: 231128-30-01 Grab 11/28/23
Parameters Results Analysis Date Reporting Limit Method
8260 Attached 12/4/23 8260
I hereby certify that I have reviewed and approve these data. Q�� "('�
Laboratory Representative
642 Tamco Road, Reidsville, North Carolina 27320
tel.(336)342-4748 fax.(336)342-1522
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 4 of 6
MERITECH, INC.
Environmental Laboratories
Laboratory Certification #165
Client:
Statesville Analytical Meritech ID#:
12012331
Project:
COB
Analysis:
12/04/23
Client Sample ID:
231 128-30-01
Analyst:
VWV
Sample Collection:
1 1/28/23
Dilution Factor:
I
Report Date:
12/12/23
SW-846-8260D VOLATILE ORGANICS - Water
Acetone
8.66 ug/L
cis-1,3-Dichloropropene
<0.500 ug/L
Benzene
<0.500 ug/L
trans-1,3-Dichloropropene
<0.500 ug/L
Bromobenzene
< 0.500 ug/L
Ethanol
< 50.0 ug/L
Bromodichloromethane
< 0.500 ug/L
Ethyl benzene
< 0.500 ug/L
Bromochloromethane
< 0.500 ug/L
Hexachlorobutadiene
< 0.500 ug/L
Bromoform
< 0.500 ug/L
2-Hexanone
< 1.00 ug/L
Bromomethane
< 0.500 ug/L
Isopropylbenzene
< 0.500 ug/L
2-Butanone (MEK)
< 5.00 ug/L
p-Isopropyltoluene
< 0.500 ug/L
n-Butylbenzene
< 0.500 ug/L
Methylene chloride
< 0.500 ug/L
sec -Butyl benzene
< 0.500 ug/L
Methly Isobutyl Ketone (MIBK)
< 0.500 ug/L
tert-Butylbenzene
< 0.500 ug/L
Naphthalene
< 0.500 ug/L
Carbon Tetrachloride
< 0.500 ug/L
n-Propylbenzene
< 0.500 ug/L
Chlorobenzene
< 0.500 ug/L
Styrene
< 0.500 ug/L
Chloroethane
<0.500 ug/L
1, 1, 1,2-Tetrachloroethane
<0.500 ug/L
Chloroform
1.47 ug/L
1,1,2,2-Tetrachloroethane
<0.500 ug/L
Chloromethane
< 0.500 ug/L
Tetrachloroethene (PCE)
< 0.500 ug/L
2-Chlorotoluene
< 0.500 ug/L
Toluene
< 0.500 ug/L
4-Chlorotoluene
< 0.500 ug/L
1, 1, 1 -Trichloroethane
< 0.500 ug/L
Dibromochloromethane
< 0.500 ug/L
1,1,2-Trichloroethane
< 0.500 ug/L
1,2-Dibromo-3-chloropropane
< 0.500 ug/L
Trichloroethene (TCE)
< 0.500 ug/L
1,2-Dibromoethane (EDB)
<0.500 ug/L
1,2,3-Trichlorobenzene
<0.500 ug/L
Dibromomethane
<0.500 ug/L
1,2,4-Trichlorobenzene
<0.500 ug/L
Dichlorodifluoromethane
< 0.500 ug/L
1,2,3-Trichloropropane
< 0.500 ug/L
1, 1 -Dichloroethane
< 0.500 ug/L
Trichlorofluoromethane
< 0.500 ug/L
1,2-Dichloroethane
<0.500 ug/L
1,2,4-Trimethylbenzene
<0.500 ug/L
1,4-Dichlorobenzene
<0.500 ug/L
1,3,5-Trimethylbenzene
<0.500 ug/L
1,2-Dichlorobenzene
<0.500 ug/L
Vinyl acetate
< 1.00 ug/L
1,3-Dichlorobenzene
<0.500 ug/L
Vinyl chloride
<0.500 ug/L
1, 1 -Dichloroethene
<0.500 ug/L
m/p-Xylenes
<1.00 ug/L
cis-1,2-Dichloroethene
<0.500 ug/L
o-Xylene
<0.500 ug/L
trans-1,2-Dichloroethene
< 0.500 ug/L
1,2-Dichloropropane
<0.500 ug/L
Additional Compounds
1,3-Dichloropropane
< 0.500 ug/L
Methyl-tert-butyl ether (MTBE)
< 0.500 ug/L
2,2-Dichloropropane
< 0.500 ug/L
Isopropyl ether (IPE)
< 0.500 ug/L
1, 1 -Dichloropropene
<0.500 ug/L
1,2-Dichloropropene
<0.500 ug/L
1 hereby certify that I have reviewed and approve these data.
Laboratory Representative
642 Tamco Road * Reidsville, NC 27320
(336) 342-4748 Ph * info@meritechlabs.com
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 5 of 6
Chain of Custody Record (COC)
Statesville Analytical
M E R I T E C H, I N C po Box 228
122 Court St
ENVIRONMENTAL LABORATORIE' Statesville, NC 28687
642 Tamco Rd. Phone: 336-342-474,
' Reidsville NC 27320 Fax: 336-342-1522
Email: info@meritechiabs.com Attention: (�
www.meritechlabs.com How would you like your report sent?
Sample Location and/or ID #
NPDES#:
Phone:
Email:
Project:
Grcle all that apply. Email ( eferred) , Fax, Mail
Sampling Dates & Times Person Taking Sample (Sign/Print):
Start End Comp? # of
Date Time Date Time Grab? Cont. Test(s) Require
II (zoo G l
't " 2 V2(o0 G W vo G
Vlethod of
"' Dechlorination
Comments:
ihipment:
J UPS
J Fed Ex
Are th ults f l
Relinquished 1 '
Hand Delivery
L
Other
Relinquished by:
Relinquished by -.-
of
Ammonia, Cyanide, Phenol and TKN samples must be done in the field prior to preservatic
rposes? Yes No ❑ Report results in: mg/L
D, Time: ` Received by
D te: Time: Received by:
�"-Z
Date: Time: R rved by Lab:
Turn Around Time*
`RUSH work needs prior approval.
St d 10 da - 5_ Days 2
Lamb Use Only
J On Ice? [-PHOK?
1.1 Yes / No Cl OK?
Temperature Upon
Receipt: �CL
Compositor #
�/ Jug #
Q mg/kg ❑ ug/L ❑
1pate:`/—Z Time:
(Date: Time:
�atc� P!n
rn
N O
00
00
o a
00
00
N
U
z
ai
V)
4-
m
•
00
N
N
x
0
m
0