NCG120095_DMR_20240501

NC Department of
Environmental Quality
4
Received
Winston-Salem/Forsyth County MAY 0 1 2024
,,
lJtilities
Water•Wastewater•Solid Waste Winston-S:lem
Old Salisbury Road Landfill,3336 Old Salisbury Road,Winston-Salem,NC 27127 Regional Gtl r.
0:336-727-8000, F:336-661-4905,utilities.cityofws.org
April 26, 2024
Attn: DEMLR Stormwater Program
North Carolina Department of Environmental Quality
Division of Mineral, Energy,and Land Resources,Stormwater Division
Land Quality Section,Winston-Salem Regional Office
450 West Hanes Mill Road,Suite 300
Winston-Salem, NC 27105
Re: Monthly NPDES Compliance Submittal for March 2024
Old Salisbury Road Landfill,Forsyth County,North Carolina
Permit No. NCG120095
To whom it may concern:
As you are aware, the Winston-Salem/Forsyth County City/County Utilities Commission is monitoring
stormwater on a monthly basis under Permit No. NCG120095 at the Old Salisbury Road Landfill located at
3336 Old Salisbury Road in Winston-Salem, North Carolina (NC).
Monthly samples were collected from monitoring points with discharge on March 6, 2024. During this
event,two outfalls (#1, and#11)were sampled and two outfalls(#6,and#7) did not discharge and were
not sampled, The required discharge monitoring report(DMR) is attached for the March 2024 event.
Also note that we are awaiting a response to our January 28, 2020, submittal related to non-routine
testing as part of the Work Plan for fecal coliform exceedances. If you have any questions or require any
additional information,please contact us. We appreciate your assistance with this project.
Sincerely,
WINSTON-SALEM/FORSYTH COUNTY CITY/COUNTY UTILITIES COMMISSION
i. L9V
-
Gordon Dively
Solid Waste Operations Manager
Attachment: DMR
C: Jamal Clark, Stormwater Operations Supervisor, City of Winston-Salem,Suite 232, City Hall, 101
N. Main Street, Winston-Salem, NC, 27101, P.O. Box 2511, Winston-Salem, NC, 27102-2511,
[e-mail]
George Wegmann, WSP USA Inc., 5B Oak Branch Drive, Greensboro, NC, 27047,
george.wegmann@wsp,com
City Council:Mayor Allen Jolnes;Denise D.Adams,Mayor Pro Tempore,North Ward;Barbara Hanes Burke,Northeast Ward;Robert C.Clark,West Ward;
John C.Larson,South Ward;Jeff Macintosh,Northwest Ward;Kevin Mundy,Southwest Ward;Annette Scipplo,East Ward;James Taylor,Jr.,Southeast Ward;City Manager:
Lee D.Garrity
County Commissioners:Don Martin,Chair;Gloria D.Whlsenhunt,Vice Chair;Dan Besse;Richard V.Linville;Tonya D.McDaniel;David R.Plyler;Malishal Woodbury;County
Call 311 or 336 727 8000
Manager:Dudley Watts,Jr.
[e-mail] Winston-Salem/Forsyth County Utility Commission:L.Wesley Curtis,Jr.,Chair;Chris Parker,Vice Chair;Simpson 0.Brown,Jr.;Harold Eustache;Tom Griffin;Yvonne H.
Hines;Hugh W.Jernigan;Duane Long;Calvin McRae;Charles Wilson;Allan Younger

N C Department of
Environmental Quality
Received
NCDEQ Division of Energy, Mineral and Land Resources MAY 0 1 2024
Stormwater Discharge Monitoring Report(DMR)Form for NCG120000
Landfills Winston-S;;lem
Click here for Instructions Regional Office
Complete,sign,scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report(DMR)Upload 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, NCG12 0095 Person Collecting Samples: Nicolas Tejeda-Torres
Facility Name: Old Salisbury Road Landfill Laboratory Name:Pace Analytical
Facility County:Forsyth Laboratory Cert. No.: NC633
Discharge during this period:❑✓ 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)? II
A copy of this DMR has been uploaded electronically via https://edocs.deq.nc.gov/Forms/SW-DMR ❑Yes ✓ No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities—Benchmarks in(Red)
Parameter Parameter Outfall#1 Outfall #11 Outfall Outfall Outfall
Code
N/A Receiving Stream Class C C
N/A Date Sample Collected MM/DD/YYYY 3/6/2024 3/6/2024
46529 24-Hour Rainfall in inches 0.36 0.36
C0530 TSS in mg/L(100 or 501 52.8 1090
00400 pH in standard units(6.0—9.0) 7.10 6.97
00340 Chemical Oxygen Demand in mg/L
(120) 35.0 71.0
31616 Fecal Coliform in#per 100 ml(1000) 124 85.0
Additional parameters for outfalls in drainage areas that use>55 gallons per month of new hydraulic oil on average
00552 Non-Polar Oil&Grease in mg/L(15)
NCOIL Estimated New Motor/Hydraulic Oil
Usage in gal/month
* Outfalls to Outstanding Resource Waters(ORW),High Quality Waters(HOW),Trout Waters(Tr)and Primary Nursery Areas(PNA)
have a benchmark TSS limit of 50 mg/t.All other water classifications have a benchmark of 100 mg/L
Notes(optional):
"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,includin e possibility of fines and imprisonment for knowing violations."
)1644 Li/ koz,i
Signature of Permittee or Dele ed Authorized Individual Date
Email Address [e-mail] Phone Number 336-734-1502

Pace Analytical Services,LLC
9800 Kincey Ave. Suite 100
acex Huntersville,NC 28078
[phone]
NCr DepartmentQual of
EnvironmentalQuality
Received
March 14, 2024 2024 0.1 2024
Winston-S7Iem
Regional Office
Ben Draper
WSP
58. Oak Branch Drive
Greensboro, NC 27407
RE: Project: OSR C&D Landfill
Pace Project No.: 92717090
Dear Ben Draper:
Enclosed are the analytical results for sample(s)received by the laboratory on March 06,2024. 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-Eden
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
Eben Buchanan
[e-mail]
[phone]
Project Manager
Enclosures
cc: George Wegmann,WSP USA, Inc.
Q p«Fp
,-,
REPORT OF LABORATORY ANALYSIS
', This report shall not be reproduced,except in full,
5w without the written consent of Pace Analytical Services,LLC. Page 1 of 15
e.s 'ii/

Pace Analytical Services,LLC
9800 Kince Ave. Suite 100
ace. Huntersville,NC 28078
[phone]
CERTIFICATIONS
Project: OSR C&D Landfill
Pace Project No.: 92717090
Pace Analytical Services Asheville
2225 Riverside Drive,Asheville,NC 28804 South Carolina Laboratory ID:99030
Florida/NELAP Certification#:E87648 South Carolina Certification#:99030001
North Carolina Drinking Water Certification#:37712 Virginia/VELAP Certification#:460222
North Carolina Wastewater Certification#:40
Pace Analytical Services Eden
205 East Meadow Road Suite A,Eden,NC 27288 North Carolina Wastewater Certification#:633
North Carolina Drinking Water Certification#:37738 Virginia/VELAP Certification#:460025
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 15

Pace Analytical Services,LLC
Pace. 9800 Kincey Ave. Suite 100
Huntersville,NC 28078
[phone]
SAMPLE ANALYTE COUNT
Project: OSR C&D Landfill
Pace Project No.: 92717090
Analytes
Lab ID Sample ID Method Analysts Reported Laboratory
92717090001 Pond I SM 2540D-2015 VLG 1 PASI-E
SM 9222D-2015 DAW 1 PASI-E
SM 5220D-2011 JP1 1 PASI-A
92717090002 Pond II SM 2540D-2015 VLG 1 PASI-E
SM 9222D-2015 DAW 1 PASI-E
SM 5220D-2011 JP1 1 PASI-A
PASI-A=Pace Analytical Services-Asheville
PASI-E= Pace Analytical Services-Eden
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 15

Pace Analytical Services,LLC
ace./�, 9800 Kincey Ave. Suite 100
/1/ _G Huntersville,NC 28078
{•�V [phone]
ANALYTICAL RESULTS
Project: OSR C&D Landfill
Pace Project No.: 92717090
Sample: Pond I Lab ID: 92717090001 Collected: 03/06/24 11:25 Received: 03/06/24 13:00 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
2540D Total Suspended Solids Analytical Method:SM 2540D-2015
Pace Analytical Services-Eden
Total Suspended Solids 52.8 mg/L 4.1 1 03/07/24 09:22
MBIO 9222D Fecal Coliform EDN Analytical Method:SM 9222D-2015 Preparation Method:SM 9222D-2015
Pace Analytical Services-Eden
Fecal Coliforms 124 CFU/100 mL 1.0 1 03/06/24 18:04 03/07/24 16:56 D6
5220D COD Analytical Method:SM 5220D-2011 Preparation Method:SM 5220D-2011
Pace Analytical Services-Asheville
Chemical Oxygen Demand 35.0 mg/L 25.0 1 03/12/24 03:12 03/12/24 06:28
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
Date:03/14/2024 01:09 PM without the written consent of Pace Analytical Services,LLC. Page 4 of 15

Pace Analytical Services,LLC
ace. 9800 Kincey Ave. Suite 100
Huntersville,NC 28078
[phone]
ANALYTICAL RESULTS
Project: OSR C&D Landfill
Pace Project No.: 92717090
Sample: Pond II Lab ID: 92717090002 Collected: 03/06/24 11:53 Received: 03/06/24 13:00 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
2540D Total Suspended Solids Analytical Method:SM 2540D-2015
Pace Analytical Services-Eden
Total Suspended Solids 1090 mg/L 25.0 1 03/08/24 11:20
MBIO 9222D Fecal Coliform EDN Analytical Method:SM 9222D-2015 Preparation Method:SM 9222D-2015
Pace Analytical Services-Eden
Fecal Coliforms 85.0 CFU/100 mL 1.0 1 03/06/24 18:04 03/07/24 16:56 D6
5220D COD Analytical Method:SM 5220D-2011 Preparation Method:SM 5220D-2011
Pace Analytical Services-Asheville
Chemical Oxygen Demand 71.0 mg/L 25.0 1 03/12/24 03:12 03/12/24 06:28
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
Date:03/14/2024 01:09 PM without the written consent of Pace Analytical Services,LLC. Page 5 of 15

Pace Analytical Services,LLC
ace® 9800 Kincey Ave. Suite 100
Huntersville,NC 28078
[phone]
QUALITY CONTROL DATA
Project: OSR C&D Landfill
Pace Project No.: 92717090
QC Batch: 837047 Analysis Method: SM 2540D-2015
QC Batch Method: SM 2540D-2015 Analysis Description: 2540D Total Suspended Solids
Laboratory: Pace Analytical Services-Eden
Associated Lab Samples: 92717090001
METHOD BLANK: 4323575 Matrix: Water
Associated Lab Samples: 92717090001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Suspended Solids mg/L ND 2.5 03/07/24 09:18
LABORATORY CONTROL SAMPLE: 4323576
Spike LCS LCS %Rec
Parameter Units Conc. Result %Rec Limits Qualifiers
Total Suspended Solids mg/L 250 248 99 90-110
SAMPLE DUPLICATE: 4323577
92716838001 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 458 492 7
SAMPLE DUPLICATE: 4323578
92716873001 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 2990 2160 32 D6
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:03/14/2024 01:09 PM without the written consent of Pace Analytical Services,LLC. Page 6 of 15

Pace Analytical Services,LLC
(j�(/(/,/'
we,, 9800 Kincey Ave. Suite 100
Huntersville,NC 28078
[phone]
QUALITY CONTROL DATA
Project: OSR C&D Landfill
Pace Project No.: 92717090
QC Batch: 837458 Analysis Method: SM 2540D-2015
QC Batch Method: SM 2540D-2015 Analysis Description: 2540D Total Suspended Solids
Laboratory: Pace Analytical Services-Eden
Associated Lab Samples: 92717090002
METHOD BLANK: 4326467 Matrix: Water
Associated Lab Samples: 92717090002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Suspended Solids mg/L ND 2.5 03/08/24 11:17
LABORATORY CONTROL SAMPLE: 4326468
Spike LCS LCS %Rec
Parameter Units Conc. Result %Rec Limits Qualifiers
Total Suspended Solids mg/L 250 238 95 90-110
SAMPLE DUPLICATE: 4326469
92717102001 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 129 145 12
SAMPLE DUPLICATE: 4326470
92717257001 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 716 720 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:03/14/2024 01:09 PM without the written consent of Pace Analytical Services,LLC. Page 7 of 15

Pace Analytical Services,LLC
9800 Kincey Ave. Suite 100
ce® Huntersville,NC 28078
[phone]
QUALITY CONTROL DATA
Project: OSR C&D Landfill
Pace Project No.: 92717090
QC Batch: 837444 Analysis Method: SM 9222D-2015
QC Batch Method: SM 9222D-2015 Analysis Description: 9222D Fecal Coliform(MF)-EDN
Laboratory: Pace Analytical Services-Eden
Associated Lab Samples: 92717090001,92717090002
METHOD BLANK: 4326345 Matrix: Water
Associated Lab Samples: 92717090001,92717090002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Fecal Coliforms CFU/100 mL ND 1.0 03/07/24 16:56
METHOD BLANK: 4326347 Matrix: Water
Associated Lab Samples: 92717090001,92717090002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Fecal Coliforms CFU/100 mL ND 1.0 03/07/24 16:56
METHOD BLANK: 4326349 Matrix: Water
Associated Lab Samples: 92717090001,92717090002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Fecal Coliforms CFU/100 mL ND 1.0 03/07/24 16:56
METHOD BLANK: 4326350 Matrix: Water
Associated Lab Samples: 92717090001,92717090002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Fecal Coliforms CFU/100 mL ND 1.0 03/07/24 16:56
METHOD BLANK: 4326351 Matrix: Water
Associated Lab Samples: 92717090001,92717090002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Fecal Coliforms CFU/100 mL ND 1.0 03/07/24 16:56
METHOD BLANK: 4326352 Matrix: Water
Associated Lab Samples: 92717090001,92717090002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Fecal Coliforms CFU/100 mL ND 1.0 03/07/24 16:56
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:03/14/2024 01:09 PM without the written consent of Pace Analytical Services,LLC. Page 8 of 15

Pace Analytical Services,LLC
ace. 9800 Kincey Ave. Suite 100
Huntersville,NC 28078
[phone]
QUALITY CONTROL DATA
Project: OSR C&D Landfill
Pace Project No.: 92717090
METHOD BLANK: 4326353 Matrix: Water
Associated Lab Samples: 92717090001,92717090002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Fecal Coliforms CFU/100 mL ND 1.0 03/07/24 16:56
SAMPLE DUPLICATE: 4326346
92717085001 Dup
Parameter Units Result Result RPD Qualifiers
Fecal Coliforms CFU/100 mL 29.0 21.0 32 D6
SAMPLE DUPLICATE: 4326348
92717083002 Dup
Parameter Units Result Result RPD Qualifiers
Fecal Coliforms CFU/100 mL 5.0 6.0 18 D6
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:03/14/2024 01:09 PM without the written consent of Pace Analytical Services,LLC. Page 9 of 15

Pace Analytical Services,LLC
ace. 9800 Kincey Ave. Suite 100
Huntersville,NC 28078
[phone]
QUALITY CONTROL DATA
Project: OSR C&D Landfill
Pace Project No.: 92717090
QC Batch: 838275 Analysis Method: SM 5220D-2011
QC Batch Method: SM 5220D-2011 Analysis Description: 5220D COD
Laboratory: Pace Analytical Services-Asheville
Associated Lab Samples: 92717090001,92717090002
METHOD BLANK: 4330160 Matrix: Water
Associated Lab Samples: 92717090001,92717090002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Chemical Oxygen Demand mg/L ND 25.0 03/12/24 06:24
LABORATORY CONTROL SAMPLE: 4330161
Spike LCS LCS %Rec
Parameter Units Conc. Result %Rec Limits Qualifiers
Chemical Oxygen Demand mg/L 750 767 102 90-110
MATRIX SPIKE&MATRIX SPIKE DUPLICATE: 4330162 4330163
MS MSD
92717030001 Spike Spike MS MSD MS MSD %Rec
Parameter Units Result Conc. Conc. Result Result %Rec %Rec Limits RPD Qual
Chemical Oxygen Demand mg/L ND 100 100 132 125 108 101 90-110 5 R1
MATRIX SPIKE&MATRIX SPIKE DUPLICATE: 4330164 4330165
MS MSD
92717130005 Spike Spike MS MSD MS MSD %Rec
Parameter Units Result Conc. Conc. Result Result %Rec °A)Rec Limits RPD Qual
Chemical Oxygen Demand mg/L 28.2 100 100 134 139 106 110 90-110 3
Results presented on this page are in the units indicated by the"Units"column except where an alternate unit is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
Date:03/14/2024 01:09 PM without the written consent of Pace Analytical Services,LLC. Page 10 of 15

Pace Analytical Services,LLC
9800 KinceyAve. Suite WOaCe Huntersville,NC 28078
[phone]
QUALIFIERS
Project: OSR C&D Landfill
Pace Project No.: 92717090
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.
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%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-Nitrosodiphenylamine decomposes and cannot be separated from Diphenyfamine 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
D6 The precision between the sample and sample duplicate exceeded laboratory control limits.
R1 RPD value was outside control limits.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
Date:03/14/2024 01:09 PM without the written consent of Pace Analytical Services,LLC. Page 11 of 15

Pace Analytical Services,LLC
ace 9800 Kincey Ave. Suite 100
Huntersville,NC 28078
[phone]
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: OSR C&D Landfill
Pace Project No.: 92717090
Analytical
Lab ID Sample ID QC Batch Method QC Batch Analytical Method Batch
92717090001 Pond I SM 2540D-2015 837047
92717090002 Pond II SM 25400-2015 837458
92717090001 Pond I SM 92220-2015 837444 SM 92220-2015 837446
92717090002 Pond II SM 9222D-2015 837444 SM 92220-2015 837446
92717090001 Pond I SM 52200-2011 838275 SM 52200-2011 838289
92717090002 Pond II SM 5220D-2011 838275 SM 5220D-2011 838289
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
Date:03/14/2024 01:09 PM without the written consent of Pace Analytical Services,LLC. Page 12 of 15

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DC#_Title: ENV-FRM-HUN1-0083 v03_Sample Condition Upon Receipt
-(: ace
un.i CAL unas
Effective Date: 12/01/2023
Laboratory receiving samples:
Asheville❑ Eden❑ Greenwood❑ Huntersville❑ Raleigh❑ Mechanicsville❑ Atlanta❑ KernersvilleZ
Sample Condition Client Name:
Upon Receipt w (+r Project#: Cc fl.
,
Courier: ❑fed Ex ❑UPS 1 ❑LISPS [Client C., y{ l'
0 Commercial ❑Pace ['Other: L G,,n J a-, I
Custody Seal Present? Oyes [ 'No Seals Intact? Oyes ❑No ON/A s
Date/Initials Person Examining Contents:
Packing Material: ❑Bubble Wrap ❑Bubble Bags [None ❑ Other Biological Tissue Frozen?
Thermometer: Oyes ONo EJ/A
0 IR Gun ID: jc4. r U U L Type of Ice: [ Wet ['Blue ONone
? r Correction Factor:
Cooler Temp: Add/Subtract(°C) — • 2_ Temp should be above freezing to 6°C
Cooler TempCorrected C ❑Samples out of temp criteria.Samples on ice,cooling process
(T )• has begun
USDA Regulated Soil([ 'N/A,water sample)
Did samples originate in a quarantine zone within the United States:CA,NY,or SC D d samples originate from a foreign source(internationally,
(check maps)?❑Yes ONo including Hawaii and Puerto Rico)?❑Yes ❑No
__. Comments/Discrepancy:
Chain of Custody Present? E)Yes DNo ON/A _1.
Samples Arrived within Hold Time? 6Yes ONo ON/A 2.
Short Hold Time Analysis(<72 hr.)? (f�Yes ONo ON/A. 3. F[ C et
Rush Turn Around Time Requested? j]Ye% ilNo QN/A 4.
Sufficient Volume? gri,e, No jN/A S.
Correct Containers Used? (Ves ONo ON/A 6.
-Pace Containers Used? tires ONo ON/A
Containers Intact? [Ices ONo ON/A 7.
Dissolved analysis:Samples Field Filtered? ❑Yes ONo ON/A 8.
Sample Labels Match COC? O es ❑No ON/A 9
-Includes Date/Time/ID/Analysis Matrix.
Headspace in VOA Vials(>5 6mm)7 ❑Yes ONo (3N/A 10.
Trip Blank Present? ❑Yes ❑No 9 /A 11.
Trip Blank Custody Seals Present? ['Yes ONo 1 _N/A _
COMMENTS/SAMPLE DISCREPANCY Field Data Required? Oyes ONo
Lot ID of split containers:
CLIENT NOTIFICATION/RESOLUTION
Person contacted: Date/Time:
Project Manager SCURF Review: Date:
Project Manager SRF Review: Date:
Qualtrax 1D:69614 Page 1 of 2 Page 14 of 15

DC#_Title: ENV-FRM-HUN9-0083 v03_Sample Condition Upon Receipt
ace
Effective Date:12/O1/2023
*Check mark top half of box if pH and/or dechlorination is verified and Project#
within the acceptance range for preservation samples.
Exceptions:VOA,Col form,TOC,O I and Grease,DR0/8015(water)DOC,1tHg
"Bottom half of box is to list number of bottles
***Check all unpreserved Nitrates for chlorine
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J J u S u N Z C U ? = Z ? ry a } 10 ao $ J P c
u _ u u J = ` U 'a c M J w n '� 7
u ✓ a! al d y N 2 2 D 2 Y 1, ° J L = al
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pH Adjustment Log for Preserved Samples
Sample ID Type of Preservative pH upon receipt Date preservation adjusted Time preservation Amount of Preservative tot fl •
adjusted added
Note: Whenever there is a discrepancy affecting North Carolina compliance samples,a copy of this form will be sent to the North Carolina DENR Certification Office(.e.
Out of hold,incorrect preservative,out of temp,incorrect containers.
Qualtrax ID:69614 Page 2 of 2
Page 15 of 15