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Home My WebLink AboutWQ0007507_Monitoring - 01-2024_20240705Monitoring Report Submittal Permit Number#* Name of Facility:* Month: * January Report Information Type * GW-59 Confirmation Email Address: Name of Submitter: * Signature: Date of submittal: Initial Review WQ0007507 Pasquotank County Industial Park Year:* 2024 Upload Document* Jan gw 59.pdf 6.76MB PDF Only Please upload one PDF containing all applicable monitoring reports (i.e., NDMR, NDAR-1, NDAR-2, NDMLR, GW-59). raperw@co.pasquotank.nc.us Ronnie Wayne Raper Reviewer: Wanda.Gerald 7/5/2024 This will be filled in automatically Is the project number correct?* WQ0007507 Is the monitoring report accepted?* Yes No Regional Office* Washington Reviewer: _anonymous Review Date: 7/8/2024 GROUNDWATER QUALITY MONITORING: COMPLIANCE REPORT FORM FACILITY INFORMATION Please Facility Name: Pasquotank County Industrial Park Permit Name (if different): _ Facility Address: P.O. Box 39 Elizabeth City NC 27909 a' SUBMIT FORM ON YELLOW PAPER ONLY County Pasquotank Contact Person: R.Wayne Raper Telephone#: 252-330-4006 Well Location/Site Name: WWTP-No thside Road No. of wells to be sampled: 6 DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT 1617 MAIL SERVICE CENTER. RALEIGH, NC 27699-1617 Phone: (919) 733-3221 PERMIT Number: Expiration Date: June 30, 2028 Non -Discharge W00007507 UIC NPDES Other TYPE OF PERMITTED OPERATION BEING MONITORED 01 Lagoon ❑ Remediation: Infiltration Gallery Spray Field ❑ Remediation: ❑ Rotary Distributor ❑ Land Application of Sludge ❑ Water Source Heat Pump ❑ Other: WELL ID NUMBER from Permit : N1W-1 ( ) Date sample collected: 1/25/24 FIELD ANALYSES: If WELL Well Depth: 20 ft. Well Diameter: 2 in. H o0400: 5.9 P units Temp. oeolo: C WAS DRY at Depth to Water Level 82546:7.61 ft. below measuring point Screened Interval: 15 ft. to 20 ft_ Spec. Cond. 00094: ur hos time of Measuring Point is 2 ftabove land surface Relative M.P. Elevation: 13.53 ft. Odor 00085: sampling, Volume of water pumped/bailed before sampling: 2.0 gallons checkAppearance Samples for metals were collected unfiltered: DYES ❑ NO and field acidified: ❑YES ❑ NO here: ❑ LABORATORY INFORMATION Date sample analyzed: Laboratory Name: Environment 1, Inc. PARAMETERS NOTE: Values should reflect dissolved and colloidal Certification No. 10 COD 00335 mg/L concentrations. Nitrite (NO2) as N 00615 mg/L Pb - Lead 01051 Coliform: MF Fecal 31616 <1 Nitrate (NO3) as N 00620 <0.04 mg/L ug/L/100mL Zn - Zinc 01092 Coliform: IMF Total 31504 /100mL Phosphorus: Total as P 00665 1.51 mg/L mg/L (Note. Use MPN method for highly [urDia samples) issolved Orthophosphate 70507 mg/L Other (Specify Compounds and Concentration Units): Solids:Total 70300 160 mg/L Al - Aluminum 01105 mg/L pH (Lab) 00403 units Ba - Barium 01007 ug/L TOC 00680 8.05 mg/L Ca - Calcium 00916 mg/L Chloride 0094o 27 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 78732: method # Total Ammonia 00610 0.18 mg/L Mg - Magnesium 00927 mg/L (Ammonia moa Nitrogen: NH, as N: Ammonia Nllro9 _Total) method # Mn - Manganese c1o55 ug/L # TKN as N 00625 mg/L Ni - Nickel 01067 ug/L ,method method # For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L dOC Removal% Sparty Hammett, County Manager Permittee (or Authorized Agent) Name and Title - Please print or type Signature of Permi uthonzed Agent) GW-59 Rev.2/2010 (Date) GROUNDWATER QUALITY MONITORING: COMPLIANCE REPORT FORM FACILITY INFORMATION Please Print Clearly or Type Facility Name: Pasquotank Permit Name (if different): _ Facility Address: P.O. Box 39 Elizabeth City Industrial Park NC 27909 Contact Person: R. Wayne Raper Well Location/Site Name: WWTP-Northside Road SUBMIT FORM ON YELLOW PAPER ONLY County Pasquotank Tele phone#: 252-330-4006 No. of wells to be sampled: 6 DEPARTMENT OF ENVIRONMENT a NATURAL RESOURCES DIVISION OF WATER QUALITYJNFORMATION PROCESSING UNIT 1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: (919) 733-3221 PERMIT Number: Expiration Date: June 30, 2028 Non -Discharge W00007507 UIC NPDES Other TYPE OF PERMITTED OPERATION BEING MONITORED Lagoon ❑ Remediation: Infiltration Gallery Spray Field ❑ Remediation: ❑ Rotary Distributor ❑ Land Application of Sludge ❑ Water Source Heat Pump ❑ Other: WELL ID NUMBER (from Permit): MW-2 Date sample collected: 1/25/24 Well Depth: 18 ft. Well Diameter: 2 in. Depth to Water Level 82546:7.95 ft. below measuring point Screened Interval: 15 ft. to 20 ft. Measuring Point is 2 ft. above land surface Relative M.P. Elevation: 12.85 ft. Volume of water pumped/bailed before sampling: 2.0 gallons Samples for metals were collected unfiltered: ❑ YES ❑ NO and field acidified: ❑ YES ❑ NO LABORATORY INFORMATION Date sample analyzed: Laboratory Name: Environment 1, Inc. PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations. COD 00335 mg/L Nitrite (NO2) as N 00615 mg/L Coliform: MF Fecal 31616 <1 /100mL Nitrate (NO3) as N 00620 0.42 mg/L Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665 0.05 mg/L (Note: Use WN method for highly turtNd samples) Orthophosphate 70507 mg/L )issolved Solids:Total 703oo 280 mg/L Al - Aluminum oilo5 mg/L pH (Lab) 00403 units Ba - Barium 01007 ug/L TOC 00680 1.13 mg/L Ca - Calcium 00916 mg/L Chloride 00940 90 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 Phenol 32730 ug/L Fe - Iron 01045 ug/L Sulfate 00945 mg/L Hg - Mercury 719oo ug/L ipecific Conductance 0009s uMhos K - Potassium o0937 mg/L Total Ammonia oo6lo 0.07 mg/L Mg - Magnesium 00927 mg/L (Ammonia Nitrogen: NH, as N: Ammonia Nitrogen. Total) Mn - Manganese 01055 ug/L TKN as N 00625 mg/L Ni - Nickel 01,067 ug/L FIELD ANALYSES: pH 00400: 6.7 units Spec. Cond. 00094 Odor 00085: Appearance Temp. 000lo: °C µMhos Certification No, 10 Pb - Lead 01051 ug/L Zn - Zinc 01092 mg/L Other (Specify Compounds and Concentration Units): ORGANICS: (by GC, GC/MS, HPLC) (Specify test and method #. ATTACH LAB REPORT.) Lab Report Attached? ❑ Yes (1) ❑ No (0) VOC 78732 method # method # method # iga=• • - •_ • • • • I certify that, to the bes: _,Medoe and belief. the information submitted in this report �s true, accurate, and complete, and that the laboratory analytical data DtP/O-certified laboratory. I am aware that mere are significant penalties for submitting false information, including the possibility of fines and imprisonment for kn, Sparty Hammett, CountyManagerPermittee �or Authorized Aqent) Name and Title - Please print -or type Sicinature of P1 m e or Authorized ApertV, I GW-59 Rev. 2,12010 , method # mg/L VOC Removal% If WELL DRY at time of sampling, check here:❑ GROUNDWATER QUALITY MONITORING: COMPLIANCE REPORT FORM Facility Name: Pasquotank Permit Name (if different): _ Facility Address: P.O. Box 39 Elizabeth City Ij Clearly or County Industrial Park SUBMIT FORM ON YELLOW PAPER ONLY NC 27909 County Pasquotank Contact Person: R. Wayne Raper Telephone#: 252-330-4006 Well Location/Site Name: WWTP-Northside Road No. of wells to be sampled: 6 IDEPARTMENT OF ENVIRONMENT 8 NATURAL RESOURCES DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT 1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: (919) 733.3221 PERMIT Number: Expiration Date: June 30, 2028 Non -Discharge W00007507 UIC NPDES Other TYPE OF PERMITTED OPERATION BEING MONITORED 0 Lagoon ❑ Remediation: Infiltration Gallery Spray Field ❑ Remediation: ❑ Rotary Distributor ❑ Land Application of Sludge ❑ Water Source Heat Pump ❑ Other: IWELL ID NUMBER (from Permit): MW-3 Date sample collected: 1/25/24 Well Depth: 20 ft, Well Diameter: 2 in. Depth to Water Level 82546:4.39 ft. below measuring point Screened Interval: 15 ft. to 20 ft. Measuring Point is 2 ft. above land surface Relative M.P. Elevation: 11.11 ft. Volume of water pumped/bailed before sampling: 2.5 gallons Samples for metals were collected unfiltered: ❑YES ❑ NO and field acidified: ❑ YES ❑ NO LABORATORY INFORMATION Date sample analyzed: Laboratory Name: Environment 1, Inc. PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations. COD 00335 mg/L Nitrite (NO2) as N 00615 mg/L Coliform: MF Fecal 31616 <1 /100mL Nitrate (NO,;) as N 00620 2,86 mg/L Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665 0.04 mg/L (Note Use MPN method for highly turgid sample$) Orthophosphate 70507 m /L 9 )issolved Solids:Total 703oo 370 mg/L Al - Aluminum o11 o5 mg/L pH (Lab) 00403 units Ba - Barium 01007 _ ug/L TOC oo68o 1.25 mg/L Ca -Calcium 00916 mg/L Chloride 00940 135 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 Phenol 32730 ug/L Fe - Iron 01045 ug/L Sulfate 00945 mg/L Hg - Mercury 71900 ug/L specific Conductance 00095 uMhos K - Potassium 00937 mg/L Total Ammonia oo6lo 0.13 mg/L Mg - Magnesium 00927 mg/L (Ammonia Nitrogen: NH;as N: Ammonia Nitrogen. Total) Mn - Manganese 01055 ug/L TKN as N 00625 mg/L Ni - Nickel 01067 ug/L FIELD ANALYSES: pH 00400: 6.3 units Spec. Cord. 00094: Odor 00085: Appearance Temp. 000lo °C uMhos Certification No. 10 Pb - Lead olo51 ug/L Zn - Zinc 01092 mg/L Other (Specify Compounds and Concentration Units): ORGANICS: (by GC, GC/MS, HPLC) (Specify test and method #. ATTACH LAB REPORT.) Lab Report Attached? ❑ Yes (1) ❑ No (0) VOC 78732 method # method # method # method # For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: Sparty Hammett, County Manager Permittee (or Authorized Aqent) Name and Title - Please print or type Signature of ermi (or GW-59 Rev.212010 mg/L VOC Removal% If WELL DRY at time of sampling, check here: ❑ GROUNDWATER QUALITY MONITORING: COMPLIANCE REPORT FORM FACILITY INFORMATION Please Facility Name: Pasquotank County Industrial Park Permit Name (if different): _ Facility Address: P.O. Box 39 Elizabeth City SUBMIT FORM ON YELLOW PAPER ONLY DEPARTMENT OF ENVIRONMENT 8 NATURAL RESOURCES E0VI1617 DIISON OF WATER QUALITY -INFORMATION PROCESSING UNIT Clearly or Type MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: (919) 733-3221 PERMIT Number: Expiration Date: June 30,2028 Non -Discharge WQ0007507 UIC NC 27909 act Person: R.Wayne Raper Location/Site Name: WWTP-Northside Road FELL ID NUMBER (from Permit): MW-4 'ell Depth: 20 ft. epth to Water Level 82546:3.94 ft. below measuring point easuring Point is 2 ft. above land surface )lume of water pumped/bailed before sampling: 3.0 imples for metals were collected unfiltered: ❑ YES ❑ County Pasquotank Tele phone#: 252-330-4006 No. of wells to be sampled: 6 Date sample collected: 1/25/24 Well Diameter: 2 in. Screened Interval: 15 ft. to 20 ft. Relative M.P. Elevation: 10.65 ft. gallons NO and field acidified: ❑ YES ❑ NO Date sample analyzed: Laboratory Name: Environment 1, Inc. PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations. COD 00335 mg/L Nitrite (NO2) as N 00615 mg/L Coliform: MF Fecal 31616 <1 /100mL Nitrate (NO.) as N 00620 0.34 mg/L Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665 <0.04 mg/L (Note: Use A1PN method for highly turbid samples) Orthophosphate 70507 )issolved Solids:Total 703oo 290 mg/L Al - Aluminum oil o5 mglL mg/L pH (Lab) 00403 units Ba - Barium 01007 ug/L TOC 00680 <1.00 mg/L Ca - Calcium 00916 mg/L Chloride 00940 125 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 Phenol 32730 ug/L Fe - Iron C1045 ug/L Sulfate 00945 mg/L Hg - Mercury 71900 ug/L >pecific Conductance 00095 uMhos K -Potassium 00937 mg/L Total Ammonia 00610 0.08 mg/L Mg - Magnesium 00927 mg/L (Ammonia Nitrogen; NH, as N: Ammonia Nitrogen, Total) Mn -Manganese 01055 ug/L TKN as N 00625 mg/L Ni - Nickel 01067 ug/L For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs. PDES Other YPE OF PERMITTED OPERATION BEING MONITORED ❑■ Lagoon ❑ Remediation: Infiltration Gallery Spray Field ❑ Remediation: ❑ Rotary Distributor ❑ Land Application of Sludge ❑ Water Source Heat Pump ❑ Other: FIELD ANALYSES: pH 00400: 6.2 units Spec. Cond. 00094: Odor 00085 Appearance If WELI WAS Temp. 000lo: °C DRY at umhos time of Certification No. 10 Pb - Lead o1o51 ug/L Zn - Zinc 01092 mg/L Other (Specify Compounds and Concentration Units): ORGANICS: (by GC, GC/MS, HPLC) (Specify test and method #. ATTACH LAB REPORT.) Lab Report Attached? ❑ Yes (1) ❑ No (0) VOC 78732: method # method # method # method # mg/L Effluent Total VOCs: Sparty Hammett, County Manager Permittee (or Authorized Agent) Name and Title - Please print or type Signalure of GW-59 Rev.2/2010 mg/L VOC Removal% check here:❑ GROUNDWATER QUALITY MONITORING: COMPLIANCE REPORT FORM FACILITY INFORMATION Please Facility Name: Pasquotank County Industrial Park Permit Name (if different): _ Facility Address: P.O. Box 39 Elizabeth City SUBMIT FORM ON YELLOW PAPER ONLY or Type NC 27909 County Pasquotank Pi Contact Person: R. Wayne Raper Telephone#: 252-330-4006 Well Location/Site Name: WW T P-Northside Road No. of wells to be sampled: 6 (DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT 1617 MAIL SERVICE CENTER, RALEIGH, INC 27699-1617 Phone: (919) 733.3221 PERMIT Number: Expiration Date: June 30, 2028 Non -Discharge W00007507 UIC NPDES Other TYPE OF PERMITTED OPERATION BEING MONITORED 0 Lagoon ❑ Remediation: Infiltration Gallery Spray Field ❑ Remediation: ❑ Rotary Distributor ❑ Land Application of Sludge ❑ Water Source Heat Pump ❑ Other: WELL ID NUMBER from Permit : MW-5 ( ) Date sample collected: 1/25/24 FIELD ANALYSES: If WELL Well Depth: 20 ft. Well Diameter: 2 in. H 00400: 6.1 P units Temp. ooa10: C WAS DRY at Depth to Water Level 82546: 5.33 ft. below measuring point Screened Interval: 15 ft. to 20 ft. Spec. Cond. 00094: µMhos time of Measuring Point is 2 ft. above land surface Relative M.P. Elevation: 10.65 ft. Odor 00085: sampling, Volume of water pumped/bailed before sampling: 2.5 gallons check Samples for metals were collected unfiltered: ❑YES ElNO and field acidified: ❑YES ElNO Appearance here: ❑ LABORATORY INFORMATION Date sample analyzed: Laboratory Name: Environment 1, Inc. PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations. Certification No. 10 COD 00335 mg/L Nitrite (NO2) as N 00615 mg/L Pb - Lead o1o51 Coliform: MF Fecal 31616 <1 /100mL Nitrate (NO3) as N 00620 0.27 mg/L ug/L Zn - Zinc 01092 Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665 0.09 mg/L mg/L (Note Use MPN method for highly turbid samples) Orthophosphate 70507 Dissolved mg/L Other (Specify Compounds and Concentration Units): Solids:Total 703oo 230 mg/L At -Aluminum o11o5 mg/L pH (Lab) 00403 units Ba - Barium 01007 ug/L TOC oo68o 1.19 mg/L Ca -Calcium oosls mg/L Chloride 00940 97 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 00o95 µMhos K - Potassium 00937 mg/L VOC 79732, method # Total Ammonia 00610 0.08 mg/L Mg - Magnesium 00927 mg/L (Ammonia Nitrogen: NH, as N: Ammonia Nitrogen, Total) Mn -Manganese 01055 ug/L method # TKN as N 00625 mg/L Ni - Nickel 01067 ug/L .method # method # For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs: mg/L Effluent Total VOCs: mg/L VOC Removal% Sparty Hammett, County Manager Permittee (or Authorized Aqent) Name and Title - Please print or type Signature of Perm ee or Authorzed A_ ent) - �••-! GW-59 Rev.2/2010 (Date) .wono i FU Mw LAN r tLL.UVV VAYtK UNLY • 'GROUNDWATER QUALITY MONITORING: DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES • • COMPLIANCE REPORT FORM DIVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT FACILITY INFORMATION Please Print Clearly or Type 1617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: (919) 733.3221 Facility Name: Pasquotank County Industrial Park PERMIT Number: Expiration Date: June 30, 2028 Permit Name (if different): Non -Discharge W00007507 UIC Facility Address: P-O. Box 39 NPDES Other Elizabeth City NC TYPE OF PERMITTED OPERATION BEING MONITORED 27909 County Pasquotank Lagoon 9 ❑Remediation: Infiltration Gallery Spray Field ❑ Remediation: Contact Person: R.Wayne Raper Telephone#: 252-330-4006 ❑ Rotary Distributor ❑ Land Application of Sludge Well Location/Site Name: WWTP-Northside Road No. of wells to be sampled: 6 ❑ Water Source Heat Pump ❑ Other: WELL ID NUMBER from Permit : MW 6 ( ) Date sample collected: 1/25i24 Well Depth: 18 ft. Well Diameter: 2 in. Depth to Water Level 82546:11.83 ft. below measuring point Screened Interval: 15 ft- Measuring Point is 2 ft. above land surface Relative M.P. Elevation: 14.64 Volume of water pumped/bailed before sampling: 3.6 gallons El Samples for metals were collected unfiltered: YES ❑ NO and field acidified: YES to 20 ft. ft. ❑ NO FIELD ANALYSES: pH 00400: 6.2 units Temp. 000lo: °C Spec. Cond. 00094: µMhos Odor 00085: Appearance If WELL WAS DRY at time of sampling, check LABORATORY INFORMATION Date sample analyzed: Laboratory Name: Environment 1, Inc. PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations. Certification No. 10 COD o0335 mg/L Nitrite (NO2) as N oo615 mg/L Pb - Lead clo51 u9 /L Coliform: MF Fecal 31616 <1 /100mL Nitrate (NO3) as N 00620 0.17 mg/L Zn - Zinc 01092 m9 /L Coliform: MF Total 31504 /100mL Phosphorus: Total as P 00665 0.08 mg/L (Note: Use MPN method for highly turbid samples) Ortho hoS hate P P 70507 mg/L Other (Specify Compounds and Concentration Units): Dissolved Solids:Total 70300 120 mg/L Al - Aluminum 01105_ mg/L pH (Lab) 00403 units Ba - Barium 01007 uglL TOC 00680 1.99 mg/L Ca - Calcium 00916 m9 /L Chloride 00940 13 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 uMhos K - Potassium 00937 mg/L VOC 78732 method # Total Ammonia 00610 0.11 mg/L Mg - Magnesium 00927 mg/L method # (Ammona Nitrogen. NH3 as N: Ammonia Nitrogen, Total) Mn - Manganese 01055 ug/L TKN as N 00625 mg/L Ni - Nickel 01067 ug/L ,method # method # Fnr Qomarlintinn Q—t— rl-l- /A-_..ti -- -- •- r ••�,• �� r rVramgit- tmuent total VOCs: mg/L VOC Removal% Sparty Hammett, County Manager (-- / �Z D Permittee (or Authorized Agent) Name and Title - Please print or type Signature o e, rf,rtt or Aulho ! gent (Dane) GW-59 Rev.2!2010