NCG060235_MONITORING INFO_20190206

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
IV L&O (o0a 3 5
DOC TYPE
❑HISTORICAL FILE
51 MONITORING REPORTS
DOC DATE
o �fli 9 �a o �
YYYYMMDD

1 nuQ aura q-B 0 6 Z Oi9
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report G", jR SECTM
For guidance on filling out this form, please visit https://deq.ne.gov/about/divisions/energy-mineral-land-resources/
npdes-stormwater-gps
Permit No.: N_IC_I I I I 1 I 1 I or Certificate of Coverage No.: N_/C/G/0/ �IO1a131�
Facility Name: )Oyv.) 00 5
County: (Q q, V Phone No. 4' / `] 7 7 f J—.2 5-;2,
Inspector: KvIL L „J)if _
Date of Inspection: , I A /j `41 t ,
Time of Inspection: la: y0P„0
Total Event Precipitation (inches): r I t'uC �
All permits require qualitative monitoring to be performed during a "measurable storm event."
A "measurable storm event' is a storm event that results in an actual discharge from the permitted site
outfaIl. The previous measurable storm event must have been at least 72 hours prior. The 72-hour storm
interval does not apply if the permittee is able to document that a shorter interval is representative for
local storm events during the sampling period, and the permittee obtains approval from the local DEMLR
onal Office.
By this signature) f cei�fy that this report is accurate and complete to the best of my knowledge:
Permittee or Designee)
1. Outfall Description:
Outfall No. t Structure (pipe, ditch, etc.):e>� +etJ �+ orJ f nJ
Receiving Strea'
V_
Describe the ' dus 1al activities that occur within the outfall drai age ar
MQ 0L7a6L L-u�i Ojq c� �rt 6 u
Page 1 of 2
SWU-242, Last modified 06/01/2018

2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: C �e Rc h� u� _ $
3. Odor: Describe any disti
chlorine odor, etc.): Irii
odors that the discharge may have (i.e., smells strongly of oil, weak
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear
and 5 is very cloudy:
l 0 3 4 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stormwater discharge, where I is no solids and 5 is the surface covered with floating solids:
2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
1 �D 3 4 5
7.
8.
9.
Is there any foam in the stormwater discharge? Q Yes (M(No.
Is there an oil sheen in the stormwater discharge? QYes O/No.
Is there evidence of erosion or deposition at the outfall? O Yes (XIN0.
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may be
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
y , t
5WU-242, Last modified 06/01/2018

J
STORMWATER DISCHARGE MONITORING REPORT -�
for North Carolina Division of Energy, Mineral and Land Resources General Permit No, NCG060000
Date submitted f a� / / I
CERTIFICATE OF COVERAGE NO. NCG06 0,2 S S
FACILITY NAME 17o,nn;n�oS I?- ,-z,, L L C
COUNTY G _
PERSON COLLECTING SAMPLES e LI ,vl�
LABORATORY rIxce- f/aw�v / r cG/ Lab Cert. h 7
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR '� t) 1 a
SAMPLE PERIOD ❑ Jan -June [j?1uly-Dec
or ❑ Monthly' (month)
DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
❑Zero -flow ❑Water Supply ❑SA
Qbther W rL.
FACILITY ACTIVITIES INCLUDE {check all that apply):
❑ use/process meats ❑ use animal fats/byproducts
PLEASE REMEMBER TO SIGN ON THE REVERSE 4
Total event rainfall 2 or ❑ No discharge this period3
Outfall No.
date Sample
Collected, mo/dd/ r
TSS,
mg/L
pH,
Standard units-
COD,
mg/L
Oil and Grease,
mg/L
Fecal Coliform,
Colonies per 100 ml
Enterococcl,
Colonies per 100 ml
Benchmark
-
100 or SW
Within 6.0 — 9.0
120
30
1000'
Soo,
Parameter Code
-
COS30
00400 -
00340
.00556
31616
61211
�j
u
Only applies to facilities that use/process meats.
2The total precipitation must be recorded using data from an on -site rain gauge.
a For sampling periods with no discharge at any outfalls. You must still submit this discharge monitoring report with a checkmark here.
`See General Permit text, Table 1, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
5Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new oil per month? ❑ yes Ono
Permit Date: 11/1/2018-05/31/2021
(ifyes, complete Part 13j
SWU-249, Last Revised 11/5/2018
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new motor oil/month.
Outfall No.
Date Sample Collected
(mo/dd/yr)
24-hour rainfallamount,
inches'
New Motor Oil or
Hydraulic Oil Usage
Non -Polar O&G/Total
Petroleum Hydrocarbons
Total Suspended Solids
Benchmarks
-
-
-
15 mg/L
100 mg/L or 50 mg/O
Parameter Code
-
48529
NCOIL
00552
C0530
Footnotes from Part A also apply to Part B
*FOR PART A AND PART 8 MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART 11 SECTION B.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an orlainal copy of this DlUIR, including all "No Discharge" reports, within 30 days of receip__t offhe lab results or at end of monitoring period in the case
of "No Discharge" reports) to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"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, accur , d complete. I am aware that there are significant penalties for submitting false information, including the possibility of fines and
imprisonment fo kno ing violations."
Permittee
Permit Date: 11/1/2018-05/31/2021
a
Date
r
SWU-249, Last Revised lf/5/2018
Page 2 of 2

aceAnalytrcal.
xnrw_pacalaba.rarrr
Laboratory Report
Robert Pawelczak
Domino's Pizza Dist of NC
3100 Watetfield Drive
Garner, NC 27529
Project: Stormwaler 12114
Pace Project No.: 92410884
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
Report Date: 12/24/2018
Date Received: 12/14/2018
Sample: STORMWATER
Lab ID: 92410894001 Collected: 12/14/18 12:40 Matrix: Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
EPA 1664B
Oil and Crease
ND
mglL
4.8
12/23/18 14:57
SM 254OD-2011
Total Suspended Solids
ND
mg/L
2.7
12/18/18 00:51
SM 4500-H+B-2011
pH at 25 Degrees C
6.4
Std. Units
1.0
12/17/18 15:04 H3
SM 521OB-2011
BOD, 5 day
ND
mg1L
2.0
12/20/18 12:24
ANALYTE QUALIFIERS
H3 Sample was received or analysis requested beyond the recognized method holding time.
Reviewed by:
Chris Derouen
[phone]
[e-mail]
Charlotte Certification IDs
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
Louisiana/NELAP Certification # LAI70028
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
FioridalNELAP Certification #: E87648
Massachusetts Certification #: M-NC030
North Carolina Drinking Water Certification #: 37712
South Carolina Certification #: 99006001
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
Virginia/VELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
Virginia/VELAP Certification #: 460222
Page 1 of 2

AM:924-1.0884
4
'biif- R CHAIN-C iz5V5ZI"cbI'Request Du.-ment
.w
all relme it fields
W. r Chaln-&-Custody is a LEGAL DOCUMENT -Complete ,' -', } " � �� � j�' � � �� � � �'� �� �� ��� t''
It Billing Information:
024tON4
VA-L 7-
Adds i Container Preservative !me ItAb.
I I=M
R"WTOI &�ZLM "ic-27—COE"a"To; Preservative Tvpm (1) little acid, (2) xUlturle aft 13) hydmdOork bcK um hvdrudde. (5) zinc sambM
(6)ined anA M walurn bbuiram Lai 5miturn thkouil" 191 hexane, (A) a cadd, (B) ammonium sulfate,
COPYTO.' Site Collection info/Address: tQ arri-xi;urn troraidde, (0). TSP, (U) Unpresenied. (01 Other
Analyses Imp .777
Customer Prq)ect NarnelNumber; State: Countylatr Time Zone
lected:
IPTI I I Ict I ET
-7 Compliance :-r
Phom:qllR -7 .9uTmrom.?.re a
ErrWi: Yes ]No MiR' 7� §r FV1 �NM � _X .. I
Cmilected By (print): PurchaseOrder#- DW PWS 10 #.* AtMg
ga
42
Quoin 11" OW Location Code: :Ing.
mgg 0
%
a4 .N
Collected By isignatme)- Turnaround Date Roquired,
�R
]No
)Yes 4 r °ri OWMA, da':
Field Filtered (If app able?. IN
Sample DiWasal: Rush: 1§4 11 _1�
Same Day Next
'PT'
r
Disp— as appropriate C Return Yes )NO
120ay 1302y j ]4DaV ISDay t
JlExpeelte Chore" Apply) Analysis:
•Matrix Codes (Insert in Matrix box below): Drinking Water (DWl. Ground Water (GW), Wastewater (WI j'" 't,
Product (P),'Soll/SorrIdI (S", Oil (OL), Wipe (WP), Air (AR), 71sm tM), Bioassay (OL Vapor M, Other JOw ; r 5,y X,
Comp Collected (or Res #of
• Composite End
Cuftmersample to matrix Grab Compod" Stan) Cl Ctns
I
Date me Date Time me—
I __ till".wi A rt.'k '=)w I IVI(r,11A L7..40 1 -ems F�&11
OAto=rFtemarim/Specie) C,mdltions/Possible Hazards:
962A 'ptut(le tTn+ n'L^_ Winane
Signature) IloateMme: . ]FteccFmdby/Camporr#_(S4L-OtU-)
Signature) Datortmet Received bvlcoTpw
Date/rime:
'21431)
natefnme:

u<t
SEMI-ANNUAL STORMWATER DISCHARGE MONITORING REPORT
for North Carolina Division of Water Quality Gen ral ermit No. NCG060000
Date submitted !�
CERTIFICATE OF COVERAGE NO NCG06 O,, 3 j� SAMPLE COLLECTION YEAR �ZICJ) '?r'
FACILITY NAME �bO!Iv-�,yJa„Lo. _ L L C _ FACILITY ACTIVITIES INCLUDE (check all that apply):
COUNTY II' i use/process meats ❑ use animal fats/byproducts
PERSON COLLECTING,SAMPL S -e\ RECEIV GING'TO SALTWATERS? []YES�O
LABORATORY Ge� }+Cd Lab Cert. # G* ` N 21 20t8
PLEASE REMEMBER TO SIGN ON THE REVERSE
CENTRAL FILES _
Part A:,Stormwa,ter,Bench marks.and,Monito.ring-Results. DWR SECTION Total event rainfall or ❑ No discharge this period{
YOutfall No,
PU4le GoHe ted;"
did r
TSS,
m
pW,
Standar.tl units�m
'" CQa, ''
'L�tf.L
Rji$Q4drease, ,
r
"" Fecal Gol fam,o
Colonies er 100 ml
Capon a er
4 {.i' 14ty'J!� S
>eerich WAOMI y ,
1
,l•: ,�3
�'
' .�.00,1or 50
� Y
W�thinf6 0 9.0�
.�. y 120,
�
� 7ty 30
S
r 1000
y'�F11yr+.
h
Only applies to facilities that use/process meats.
"ihe total precipitation must be recorded using data from an on -site rain gauge.
' For sampling periods with no discharge at �_ outfalls. You must still submit this discharge monitoring report with a checkmark here,
''See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ❑ yes ❑ no
Part B: Vehicle. Maintenance Area Monitoring,Results: only for facilities averaging > 55 gal of new motor oil/month.
` x 81-19..mow �. _
tfall No. Sam le Collected,Oil and Grease,
ma/dtlCY mg/,L �,
,. p.
TSS,"
s umg/IJ �� t5tandard
o . H - t
+.� ,. p
unfts,j
New IVlotor �ga
Annuala eragem
Berilmark'7 �&J
�� �� ��,.���F F � �30�', ,�'� t,
�.� .,{ T00'�or�50�
i` •+'6.O,:e9.0�$� .
� , „= �`-',
Only applies•to facilities that use/process meats. -
The total precipitation must be recorded using data from an on -site rain gauge.
' For sampling periods with,no discharge at -an 'outfalls, you must still'submit this discharge monitoring report with a checkmark here.
4See General Permit text 'Table-3, identifyingithelespedally sensitive receiving water classifications where the more protective benchmark applies.
(if ye,s, complete Part 13)
SWLI-249 last Revised: Outobur 18, 201'
11<lge. 1 0`2

*FOR PART AND PART,B MONITOR] NG.RESULTS:
• A'BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an on inal an&one co !a 'this. DMRXincludin . all "No Dischar e" reports, within 30 -days - o recei t,a ;tNe lab results or at end o
monitorin eriodfin�theicase o "No'Disehar a"'re orts to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"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'thbse-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, .inc to the possibility of fines and imprisonment for knowing violations."
(Signature 4Permittee)
Z � d'
— �' (Date)
Additional copies of this form may be downloaded at: htt /portal.ncdenr,ort;/w(ab wows/su/tipdesswtitab-4
S W U-249
Last Revised: October 18 2017

NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this fornr, please risit: hu �a/ snt.�l.ncdct�r.oe r/wch/�:'�!�.;l ulsi d n'`iab
Permit No.: NICI I 1 1 1 1 1 1 or Certificate of Coverage No.: NfCIGI4)I 4-71007/&S7
Facility Name:
County:
Inspector: K 421
Vj
Date of Inspection:
Time of Inspection:
Phone No. 5 / Y
Total Event Precipitation (inches): / Y3 t.Jet
Was this a Representative Storm Event? (See information below) �es ❑ No
Please check your permit to verib, if Qualitative Monitoring must be performed during a representatit,e
storm event (requirements vary).
A "Representative Storm Event' is a storm event that measures greater than 0.1 inches of rainfall and that
is preceded by at least 72 hours Q days) in which no storm event measuring greater than 0.1 inches has
occurred. A single storm event may contain up to 10 consecutive hours of no precipitation.
F '!
By this skn4tre, yce4y that this report is accurate and complete to the best of my knowledge
(Sign-atMe of Permittee or Designee)
1. Outfall Description:
Outfall No. I Structure (pipe
Receiving Stream:
etc.) 110 ,1 ?a 43
Describe the nindusf rial activities that occur within the outf I drai agc
&IeL V - { _ — v.rt�3� t (�lJ�� ii 4�tv.�9 i S f 1
2. Color: Describe the color of the disc
(light, medium, dark) as descriptors-.
tisinQ basic colors (red, brown, blue, etc.) and tint
ice?
3. Odor: Describe y distinct odors that the discharge may have (i.e., smells strongly of oil, weak
chlorine odor, etc.)-, i4- _
face 1 of 2
S 1«J-'41_'-U 1'_f)b 1 3

4. Clarity: Choose the number which best describes the clarity of the discharge, where l is clear
and 5 is eery cloudy:
1 3 4 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stormwater dischar1e. where l is no solids and 5 is the surface covered with floating solids:
1 D 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge. where l is no solids and 5 is extremely muddy:
1 3 4 5
7. Is there any foam in the stormwater discharge? Yes Q
8. Is there an oil sheen in the stormwater discharge? Yes 0
9. Is there evidence of erosion or deposition at the outfall'? Yes Nc
to. Other Obvious Indicators of Stormwater Pollution:
I �
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may
be indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
S W U-2.:2-20 t_10613

acem,4xical
*ww.pacela6scam
Laboratory Report
Robert Pawefczak
Domino's Pizza Dist of NC
3100 Waterfield Drive
Garner, NC 27529
Project: Storrrlwater 5129
Pace Project No.: 92386405
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
f,
Report Date: 06/11/2018
Date Received: 05/2912018
Sample: STORMWATER
Lab ID:
92386405001 Collected: 05/29/18 14:00 Matrix: Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
SM 2540D
Total Suspended Solids
ND
mg1L
6.9
05/31/18 10:16
EPA 1664E
Oil and Grease
ND
mg1L
5.0
06/11/18 04:18
SM 9222D
Fecal Coliforms
68.3
CFU1100 mL
1.0
05/29/18 16:18
SM 4500-H+S
pH at 25 Degrees C
6.3
Std. Units
1.0
06/09/18 03:50 H6
SM 5220D
Chemical Oxygen Demand
64.0
mg1L
25.0
06/01/18 10:00
ANALYTE QUALIFIERS
H6 Analysis initiated outside of the 15 minute EPA required holding time.
Reviewed by: //,--
Chris Derouen
[phone]
[e-mail]
Raleigh Certification IDs
6701 Conference Drive, Raleigh, NC 27607
North Carolina Wastewater Certification #: 67
Charlotte Certification IDs
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
Louisiana/NELAP Certification # LA170028
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
Massachusetts Certification #: M-NC030
North Carolina Drinking Water Certification #: 37712
Eden Certification IDs
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification M 37738
North Carolina Bioassay Certification #: 16
North Carolina Drinking Water Certification #: 37731
South Carolina Certification #: 99006001
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
VirginiaNELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
VrginiaNELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
VrginialVELAP Certification #: 460025
Page 1 of 4

Document Name:
Donunent Revised. February 7, 2018
Sample Condition Upon PAwi SCU
1 of 2
Document No.:
issuing Authority:
I~CARCS-033-Rev.05
Pace Carolinas Qua4ty Office
Laboratory receiving samples:
Asheville ❑ Edeno Greenwood ❑ Huntersville ❑ Raleigh Mechanicsville[)
• Clien;0,21/mg,&S
me: Project; WO# : 92386405
El Commercial mer�al �� Dun Own lent II � III I I III I I I I I II I IlI
Ofter., 92386405
Custody Seal Present? []Yes �N0 Seals Intact? Dyes ,PNo
j7ate/Iktltlals Persao EarsrrtEnletg Contents:,,.,
Y�,L l�1
Packing Material: []Bubble Wrap ❑Bubble Sags None ❑ other BlologtcalTissue Frozen?
Thermometer []Yes []No jf V/A
Gun lD:�L �//''o''''F''l''c��e: et ❑BJeie [None ' i
Cooler Temp (*Q. Correction Factor: Add,�srbtracp('CJ
�»� Temp should be above freezing to 6'C
Confer Temp Corroded {'C1 ]' les out often crfteda. Sam OSamp P u Dn !u, cooling process
has begun
USDA Regulates! Soll N/A, water sample)
Old samples originate In quarantine zone within the United Stater+ CA, NY, or SC (check maps)? old samples originate From a foreign source (intionally,
I� v.-. /Mm" Indudl.a Hawaa and Puerto Rlmt? 171vas V.
Commenffi/DtsCrepaeeyr.
Chain of Custody Present?
oves,
r3N.
A
1.
Samples Arrived within Hold TLme7
es
No
EJ NIA
2.
Short Hold ThasAni (<72110?
N
C]N/A
3.
Rush Turn Around Tlme Requested?
es
No
JJNIA
4.
SufHdent Volume?
es
Elk.
NIA
S.
Correct Containers Used?
-Pace Containers Used?
Y
es
[]No
Na
ON/A
EINJA
6.
Containers Intact?
a
CIN.
N/
7.
Dissolved ana sks: Samples Field Flftered7
No
9 NIA
B.
Sample labels Match CW
-Includes Oate/TFrne/ID/Ana 's matriv
es
(
[]NO
CIN/A
9.
flea ace in VOA Vials (a6- mm)7
C]Yes -
ONO
A
10.
Trip Blank Present?
TripBlank Custody Seals Present?
OYes
es
[]No
No
A
tHIA
11,
t
COMMENTS/SAMPLE DISCREPANCY
Lot ID of split containers:
CLIENT NOTINCATIONAMSOLLITION
Person contacted:
Project; Manager SCURF Ravlew:
Project Manager SRF Review:
Date/Time:
Field Data Regvlmd7 (]Yes ONO
Date: 51461, V,
Date: �/ G
Page 2 of 4

Document Name,
FCM-MMRev o6
;Check mark top half of box if pH and/or dechlorination is
verified and within the acceptance range for preservation
samples.
Evapdalts: VOA, Colftrn, TOC, Op and Grease, DRO/8O15 (water) Doc, Ult
"Bottom half of box Is to list number of bottle
Document Revised: February 7, 2018
Page 1 of 2
6MIMAuthority: +
Pace rarolirtas QualiW OfRre
Project; WO# a 92386405
PM: CD1 Due Date: 06/22/18
CLIENT: 91-Domirtbs
@001
EMMON■ison
�a►�iiiiii����iii
EMSE,
ONE
son
0�iii►a��ii°i
��►iiiiiiii
Biri
o►i
ii�
a������►iiiiiiii�
iii
pH Adjustment
Log for Preserved Samples
Sample M
Typa of preservettwe
pH upon receipt
Date preservation adjusted
Time preserva8on
adjusted
Amount led
added
tot d
NMC wnenevar there a a discrepancy atfecting Norm Carolina compliance ssmples�, a copy otthis tam wal be sent to the North Carolina DEHNR Cernftmtion un¢e p.e.
Out of hold, Iruornct preservative, cut of temp. Incorrect contalners.
Page 3 of 4

.� 3'
2
i NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Mbriitoring Report
For guidance on filling out !iris fornn, please visit. htt :/I )oi-tal.nedcnr.orJweh/%vL /ti,s/sti/n do sNv#tab-4
Permit No.: NICI_I_I 1 1�1 or Certificate of Coverage No.: N1C1G1 P GI z)Vb1?1-34-1
Facility Name: wV%t xJe)S 'Y r Z7-a't'
County: VC- Pltorie'No. /9-77 93� !
Inspector: K 3e, kn. L1AJK1-
Date of Inspection: 1
Time of Inspection: 6 . 16-�4vK _ EG
EIVED
DEC 07 2u1I
Total Event Precipitation (inches).
CENTRAL. FILES
Was this a Representative Storm Event? (See information below) DI'MPTE�No
Please check your pertnit to verib, if Qualitative Monitoring insist be pe fornied during a representative
storm event (requirements vat-Y).
A "Representative Storm Event" is a storm event that measuie's`gre'ater• than 0.1 inches of rainfall and that
is preceded by at least 72 hours (3 days) in which no storm event measuring greater than 0.1 inches has
occurred. A single storm event may contain up to 10 consecutive hours of no precipitation.
By this sif atub, I certiV� the this report is accurate and complete to the best of my knowledge:
(Sign�Etare - ermittee or Designee)
1. Outfall Description:
Outfall No. ( S ructure (pipe, ditch, etc.)
Receiving Stream: W C%V, Cf Ce—
Describe the indurtal activities that occur
wn�.li.t�(1 f ithin the outfall d 'nag ares: ttzZeA 0("
aC- 1.0-F . WCL�2�o,"Te�CI in 00
2. Color- -Describe ihe'cotor "Fth disc
(light, medium, dark) as descriptors:
3. Odor: Describe
chlorine odor, etc.):
iisi g basic coto s (red, brown, blue, etc:),aitd tint
.-4-e
distinct odors that the discharge may have (i.e., smells strongly of oil, weak
S4vU-242 20120G13
Page 1 of 2

4. Clarity: Choose the number which best describes the clarity of the discharge, where l is clear f
and 5 is very cloudy: i
I U • _3 A 5
5. Floating Solids: Choose the number; which best describes the amount of floating solids in the
stormwater discharge, where f is no solids and 5 is the surface covered with floating solids:
1 D 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge, where I is no solids and 5 is extremely muddy:
DI 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes No
8. Is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes DNo
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may
be indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
s WU-242-20l lob l3

SEMI-ANNUAL STORMWATER DISCHARGE MONITORING REPORT
for North Carolina Division of Water Quality General Permit No, NCG060000
Date submitted
CERTIFICATE OF OVERAGE NO. NCG064L2 3
i
FACILITY NAME in1_p5l��et LAC _��
COUNTY 6ocz KG
PERSON COLLECTING+SAMPLE i ry
LABORATORYpCC real Lab Cert. #
Part A:,Stormwater.Benchmarks .and�Monitoring.ResuIts.
SAMPLE COLLECTION YEAR r2 d l -7
FACILITY ACTIVITIES INCLUDE (check all that apply):
❑ use/process meats ❑ use animal fats/byproducts
DISCHARGING TO SALTWATERS? ❑YES ❑✓<O
PLEASE REMEMBER TO SIGN ON THE REVERSE
Total event rainfall 2 or ❑ No discharge this period3
! Ode algIVo �pj(
C T •gK.'w.'+Y Y'.
Sampl`e1Gallected',
.4y�i�:bu1:1:� }���t.?
{ ri� „755;, *+
r `�.. {I'e• r, ♦
4;,, ;(mjU 9::
:,- pH .'ram : I
7 w�.. lN_' '� .. 1u
k7
r Standard units a
i.: 1COD; , , '
j_ x� - S
'L , :. mJ;/L ; : .�
;:..(OiliandfG`rease; 'r;
! IY . :1 .♦1. -
.a,`...�?.mg/EE.. '_�
;Feca13Co1ifarirs ;
:i rf�3'Y"I..�`✓
x_:+Co_lonies.ipe 100(inl(,,
fEnteracocci?, -
Coloniesiper,1100imk
'Beiichrrtark,�
�, -° " •
i�14Uro54,
�IfllifFiinB�4r�f9.Ot
r; IA J•i
.;500"
3, 3
N
' only applies to facilities that use/process meats.
2The total precipitation must be recorded using data from an on -site rain gauge.
3 For sampling periods with no discharge at any outfalis. You must still submit this discharge monitoring report with a checkmark here.
`'See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ❑ yes ❑ no
Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new motor oil/month.
`i(OiitfallNo':�Sample[Eollecteii;.�`
S i +� yi:✓f r
_; "r«s"u
5.�: �r1 , r —" yl f
+=°..mo
�ilandGrease;
"'i �� x— ..r
i ` :TSS:
> — 5� ••y
(pH;
w6 k ��
:.Standard�unifssr a
NewlMotorkOiliUsage, .
.. iAnnuaavera
llge{gal/,mo4. _
100ior�50
-'6i0"= 9'.0'
i Only applies'to facilities that use/process meats.
2The total precipitation must be recorded using data from an on -site rain gauge,
3 For sampling periods with -no discharge at gny,outfalls, you must-still'submit this discharge monitoring report with a checkmark here.
4See'General Permit'text,'Table,3, identifyinglthietespecially sensitive receiving water classifications where the more protective benchmark applies.
(if yes, complete Part 6)
5WU-249 Last Revised: October 18, 2012
Page 1 o1, 2

*FOR PART A AND PART-8 MONITORING: RESULTS:
• A'BENCHMARK EXCEEDANCEIRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART 11 SECTION B.
• TIER 3; HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Will an.original�andibnescopy+of 'this,DMR_includina,all "No Discharge" report$,_within-30 dayssof recei fp of -the lab results, (or at end of
mon►torinq,period in"ttie�cpsee"of "No`Disch`a" &`reports) to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"1 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 person nel,properly gather and evaluate the information submitted. Based on my inquiry of the
person or persons who manage the system, or'th'ose"persons directly responsible for gathering the information, the information submitted is,
to the best of,my,knowleclget;and belief, true, accurate, and complete. I am aware that there are significant penaities"for submitting false
information, yn&(uding the.possibility of fines and imprisonment for knowing violations."
ofiPermittee)
?-- � ,7
(Date)
Additional copies of this form may be downloaded at: http://portal.ncdenr.org/web/wgZws/su/npdesswtit:tb-4
SWU-249
Last Revised: October 18. 2012

I
Document Name: Document Revised: July 25, 2017
+ Sample Condition Upon Recei t(SCUR) Page 1 of 2
- �eA M& DocumentNo,: Issuing Authority:
F-CA" w "I (c�.43 P-c_ n,.,r, , nf?i_^
—labv►ato►yi ing-safnples: -- - -- --- ----... .- - •--- - - --- -
As eville ❑ Men Upon Recript Potn
❑Greenwood ❑ Hunters►ilie❑ Ralelghp- MechanicsvilleEClientNamei n %r Project)): WO a 92362784
Courier: []Fed Es [)UPS USPS
❑ Commercial ❑Pace QOther- 92382711814 1 1111 I 111 I
Custody Seal pres t? ❑Yes ;eats Intact? ❑Yes �3w , ///
pateJlnitlals Person Examining Contrnr���" /
Packing Material. ❑Bubble Wrap ❑Bubble Bags one [I Other Biological Tissue Frozen? /
Thermo rn t r; 7'I ❑Yes ❑No �f^
� Gu T
IRID: S�}`� !t ©Blue ❑None
Type of lees
---Cafsealan-;a ofe;4ernptwrected(!Q --—Tempshould-be-above#reezIng-to6!C --
/ ❑Samples out of temp criteria. Samples an ice, cooling process
has9egun
USDA Regulatad 5 II { water sample}
Did samples orlglna quarantine none within the United States: CA, NY, or SC (check maps)? Did samples orlgtnate from a foreign source lintematicr
- - ❑Yes Including Hawatl and Puerto Rico)7 []Yes
Cornm e n is/Discrepancy:
Chain of Cust
Y Present? es Na 171xLA
I.
Samples Arrive
I within Hold Time? No NIA
2.
Short Hold Tim
Anal is c72 hr.?_ es ❑No MIA
3,
Rush Tum Aro
nd Tlme R uestedT Des o ❑NIA
4.
Sufficient volu
e7 Na N/A
S.
Correct Contaii
-Pace Conta
ersUsed? N/A
)ers Used? ONG NIA
6.
Conlalnerslnt
7 es No N/A
7.
Dlssolvedanal
is: Samples fie!dFiltered? Y!s A
B.
Sample Labels
-includes Da
43tch C0C7 � e ❑No C'jN/4
e/Time/lD/Anal s Matrix: 1
9.
Headspace in
A Vials (?5-6mm)7 0 yes No
N/A
20.
Trip Blank Prei
Trl BlarkCus
nt? (]Yes ❑No
Seals ?resent? Yes No
N/A
N/A
11.
CLIENT
Person
Discrepancy;
Date/nme:
Field Data Required? UVes UNC
Project Mana4er SCURF Review' Dale: ir/, c
Project Manal er SRF Review: �� pate:
Note: Whenever t e 4 a discrepancy affecting North Carolina compliance samples, a copy of this form w'dl be sent to the North Carotins DEHNR Certificatkn Office (i.e.
Out of hold, incorrmt preservative, outaf temp, Incorrect containers)
Page 2 of 4

CHAIN -OF -CUSTODY 1 Analytical Request
1?!Z The Chain -of -Custody is a LEGAL DOCUMENT. All! relevant fields
,Section A Section S Section C
Required Client Information: Required Project Information: invoice Information;
i
I
Document i
.inust be completed accurately.
i Pa e ' 1
._
f 1
Company! DomifWa Pizza DM -of NC
Report To: RobertPavrelczsk
Attention:
Address: 3100 Waterfleld Drive
Copy To:
Company Name: t
Gamer NC27529
Address:
l Ifie"ul"$ `A°'ere
iw,MnV
Email: robed. Iczak ominos.com
Purchase Order#:
Pace Quota j
Phone [phone] JFax
Proiect Name: Stormaator
Pace Project Manager. chrislopher.derouen acelabs
com,
�Stiit 1, "°$tl'on�J
�Rl!jll I
Requested Due Date:
Project 0:
Pace Praflie #; i
I
�tllzn"u
"etei!'ti?31"sls'Fpea";:otl;
p.fA�4�
r!� V,
��r1; .q
MATRLx CODE
DM" wars Dw
WNW wow vVw
SAMPLE ID D8a1�°1tl OL
One Character per box. 'ire
Sample Ida must be unique raw. Ta
9
s
w
3
��j
Y
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a�
COLLECTED
a
-z
n?
Preservatives
START
ENDNN
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z
{ffiIQ.
tl!
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;�Cti
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DATE
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DATE
TIME
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6
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tlA111PLE!GO.
Lt�lr3
tfONB
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SA LERNAM��D�SIG AflR �
[ '�a1tPR4Yt-1KY
PRINT Name of SAMPLER:
SIGNATURE of SAMPLER:
��•r•
fined:
u
$
8
m $
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S
^r
3
DATE
I
,

aceAnaIXical o
J WWW..pace08b&=n
I
Laboratory Report
Robert Pawelczak
Domino's Pizza Dist of NC
3100 Waterfield Drive
Garner, NC 27529
Project: Stormwater 1119
Pace Project No.: 92362784
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
(919)8344984
Page 1 of 1
Report Date: 11/21/2017
Date Received: 11/09/2017
Sample: RETENTION POND
Lab ID: 92362784001 Collected: 11/09/17 06:15 Matrix:
Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
SM 2540D
Total Suspended Solids
32.3
mg1L
3.4
11/10/17 12:40
EPA 1664E
Oil and Grease
NO
mg/L
5.0
11/21/17 05:01
SM 9222D
Fecal Coliforms
NO
CFU1100 mL
1.0
11/09/17 12:55
SM 4500-H+B
pH at 25 Degrees C
4.3
Std. Units
1.0
11/13/17 14:05 H6
SM 5220D
Chemical Oxygen Demand
NO
mg/L
25.0
11/14/17 11:25
ANALYTE QUALIFIERS
H6 Analysis initiated outside of the 15 minute EPA required holding time.
Reviewed by:
Chris Derouen
[phone]
[e-mail]
Raleigh Certification IDs
6701 Conference Drive, Raleigh, NC 27607
North Carolina Wastewater Certification #: 67
Charlotte Certification 1Ds
9800 KinceyAve. Ste 100, Huntersville, NC 28078
LouisianalNELAP Certification # LA170028
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
Asheville Certification lDs
2225 Riverside Drive, Asheville, NC 28804
FloridalNELAP Certification #: E87648
Massachusetts Certification #: M-NC030
North Carolina Drinking Water Certification #: 37712
Eden Certification IDs
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
North Carolina Bioassay Certification #: 16
North Carolina Drinking Water Certification #: 37731
South Carolina Certification #: 99006001
Florida./NELAP Certification #: E87627
Kentucky UST Certification #: 84
VirginiaNELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
VirginiaNELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
Uirginia/VELAP Certification #: 460025 -
Page 1 of 4

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I NI -I oI "1 "1 -I -I Nf AI -I -I �_I.. _ I I
/ BPAU-125 mL Piastic Unpreserved (N/A) (CI-)
eP3U-250 m� Plasllc Unpreserved (NIA)
BPIU-1 firter iastic Unpreserved (NIA)
ORS-125 m Plastk HZS04 (pH < 2) (Cl.)
BP3N-ZS0 ml plastic HNO3 (PH < 21
4P3Z-2SO mi. Plastic ZN Acetate & NaOH (4)
MC-250 m PbAkNaOH (PH> 12) (CO
WGFU-Wide rnoutbedGlass Jar Unpreserved
AGIU-1 liter ArnberUnpreserved (N/A) (CI-)
AGIN-1 IlterAmber HO (pH < 2)
G30-250 n'L Am ber Unpreserved (N fA) (CI-)
AG1S-11irer berRZSO4(pH <21
AGJS-250 m Amber H2504 (pH < 21
AGBA(DG3A 156mLAmber NHdCt(NfAI(CI-)
OCj9H40 m VOA HCI (N/A)
VG9T-40 mL VOA Na25203 (N/A)
VG9U-40 mt VDAUepINN
DGSP40 m VOA H3P0.t (NIA)
VOAK 16 via Is per ki+5035 W (N/A)
V/GN(]vla per kl*VPH/Gaslit(N/AI
SM.125 mi SlerilePlasticIN/A —lab)
SPZT-250 m. Sterile Plastic (N/A —lab)
BP3A-250 mL Plastic INH2)2504 (9,3-9.7)
CLbitainer
VSGU-20 rnk Scintillation vial% (NIA)
GN
0 ro
0

NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out thisfornt, please visit: http:/ij)girt.tl.nctlett;-.orLYNVJ)A LJltiV•.,/.;t1/ru(k SV,-� lb-4
Permit No.: NICK
` Facility Naive:
County: JA.).0 <c
Inspector:
Date of Inspection:
Time of Inspection-
-I1 II_ — II or Certificate of Coverage No.: NICIGIOI%1Ob?13PIS
—
.T _� . I i /- — — —
9
No. 1 /1 ? 7 `7 5-;2 5-;�Z
Total Event Precipitation (inches): 1;ad-- CENTRAL FILES
DWR SECTION
Was this a Representative Storm Event? (See information below) [e�Yes ❑ No
Please check Yoar- permit to verify if Qualitative Monitoring must he performed during a representative
storm event (requirements varv).
A "Representative Storm Event' is a storm event that measures greater than 0.1 inches of rainfall and that '.
is preceded by at least 72 hours (3 days) in which no storm event measuring greater than 0.1 inches has
occurred. A single storm event may contain up to 10 consecutive hours of no precipitation.
By this sigpatffre, t Vertify that this report is accurate and complete to the best of my knowledge:
(Si�t�Pernittee or Designee)
1. Outfall Description:
Outfall No. �_ Structure pipe. ditch,
Receiving Stream: (A)Ljf_ �r_ re-e 1
Describe the in ustrial activities that occur within the
} Re-L,�3�1.00 Rod
tfall rainage
1'54�'�w
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and -tint
(light. medium, dark) as descriptors: 1_ 2. C, ��
3. Odor: Describe
chlorine odor, etc.): /J
distinct odors that the discharge may have (i.e., smells strongly of oil, weak
Page 1 of 2
Sw'U-242-20 t 20613

4. Clarity: Choose the number which best describes the clarity of the discharge. where l is clear
and 5 is very Cloudy:
2 3 4 5
7. Floating Solids: Choose the number which best describes the amount of floating solids in the
storimwater discharge. where l is no solids and 5 is the surface covered with floating solids:
0 ? 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the storm►water discharge. where 1 is no solids and 5 is extremely muddy_
I 3 4 5
7. Is there any foam in the stormwater discharge? Yes
8. Is there an oil sheen in the stormwater discharge? Yes do
9. Is there evidence of erosion or deposition at the outfall? Yes o
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Jl I
Note: I,o►v clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may,
he indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of'_
SWU-2t2-20120613

" Y _
SEMI-ANNUAL STORMWATER DISCHARGE MONITORING REPORT
for North Carolina Division of Water Qualit General Permit No. NCG060000
Date submitted �O
CERTIFICATE OF OVERAGE NO.
FACILITY NAME I
COUNTY LQCX
PERSON`COLLECTINGISAMP}ES
LA9ORAtORY?4t'oAJAvHe-e
G06
Lab Cert. # le-7
P,art.A;,Stormwater,Benchmarks,andiMonitoring.Results.,,,,,-
SAMPLE COLLECTION YEAR
FACILITY ACTIVITIES INCLUDE (check all that apply):
❑ use/process meats ❑ use animal fats/byproducts
DISCHARGIW61-(O SALTWATERS? []YES e<0
PLEASE REMEMBER TO SIGN ON THE REVERSE -)
,,,, Tgtgl!event rainfall z /,4or ❑ No discharge this period'
Outfall No.
=.
Sam le Collected,
1 mo/,dd/,yr .,
TSS,
1-: mg/iL
H
Standard units
C''f
NQO,
mg/LLr,
Qil�and Grease,
x R`. mg/L� wa'
Fecal Coliformt; =
Colonies]per 100 ml
Enterococa ,
G61onies?per41'OOlml', -I
e nclimark
;, , `? ' "�
-`� •
100 0r�F50 "
�
i 1Nittfin�6T07—T 0
; j120
" 30j ` ' "
"1.000 '
' ' ' ;' 500� Pr 'I
1t }„wt
�
t
r i_
unly applies w IdUlMeS Lna4 use/ proLe>s meals.
ZThe total precipitation must be recorded using data from anon-site,rain,gauge.
3 For sampling periods with no discharge at any outfalls. You must still submit this;discharge monitoring report with a checkmark here.
4See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Did this facility perform Vehicle Maintenance Activities'using',ri q e`,ti an 5S,galloris of new motor oil per month? ❑ yes ❑ no
Part B:.Vehicle Maintenance Area Monitoring,Results: only for facilities averaging > 55 gal of new motor oil/month.
" Outfall No.
"� '" "'
Sample Collected,
r _, ,
mo dtl/Y ...
`Oil
�'
��"�
and Gr "se; f
mg/,
TSS,'.
a }
a.
Ldard
I A" 1!�
p
'' r d�o-1
",/ units?
!NewlMotor Oil Usa e,
g"
An_ nual,average gal/mn�
100Ior.501
I
(' "?:
Only applie?to facilities that:use/process meats.
2The'total'precipitatl66 rnust'be recorded'using`dataLfrom an oK-'site rain gau' ge.
3 For sampIing�pe'riods•with,66-discharge=at-a�routfalIs,f`you must�stilh'stabmi't-tRis discharge monitoring report -with a checkmark here.
aSeetGener'al Permif`text��T6bieo3;„id'entifyi6diih erespe'cially sensitive receiving water classifications where the more protective benchmark applies.
(ifyes, complete Part B)
, It
SWU-249 Last Revised: October 18, 2012
Page I of 2

*FOR PART'AJAND-PARTtBWONITORINGiRESULTS:
• A'6ENCHMAkk"EXCEEDANCE;TRIGGERS'71ER'1 REQUIREMENTS. SEE PERMIT'PART II SECTION B.
• 2"EXCEEDANCES IN A'ROWrFOR THE`S'Xf 1E'P,�R4NIETER AT THE= SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS, SEE PERMIT PART II SECTION B.
• TIER�3:- HAS YOUR FACILITY,HAD 4 OR MORE -BENCHMARK EXCEEDENCES FOR THE -SAME, PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑
IF-YES,*HAVE YOU -CONTACTED -THE DWQ REGIONAL OFFICE? YES -❑ NO ❑
REGIONAL OFFICE CONTACT�NAME:
i= .
°IVJiail. an:oriainal aria
monit""onna:nerh4J
14 1, . a .?�
i"e�rop eo th'isj011ilR;.�inclualingiill�`"No,Dischargre"�r
elcase of '.'No_�Dscharpe"'repoi�tslao: �`
> onts r'wifhin 30.'da s°o ,recei' too-fhelab results tor a
' Division of'Water Quality
Attn: DWQ Central.Files
,1617 Mail>Service Center .
Raleigh;�NC • 27699-1617
YOU MUST SIGNTHIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"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 thatqualified personnel,properly.gather..and evaluate the information.submitted. Based. on my inquiry of the
_persobh2r persons.who.manage .thersystern, dr:those•persons;directly responsible forgather:in'g.the-information; the lnformatiori-subMitted is,
Esc. .s1 1,� �r . .�.�-'''.T,4 t`• $- �•�_ � ' � ] �,i•r+W':2 p v .^v ,, �s, .a ✓ �.
tafhe�st ofmyknowledgeatid belief,.true, accurate;-and;complet'e. I am aware that there are significant „penalties for submitting false
,inforr`ilation,:inclu ' . -the,posslbilityraf•,fines:and imprisonment for knowing violations."
7aZ
(Signa re: ermittee)".
Additional copies of this form may be downloaded at: http::/fportal.ncdenr.org/web/`wg/ws/sulnpdessw#tab-4
SWU-249 Last Revised: Octoher I$, 2012
Page 2, C,1' 2 -

v
0
CHAINOF-CUSTODY / Analytical Request Document a
The Chain -of -Custody is a LEGAL DOCUMENT. All relevant fields must be complaled accuralety,
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uocument: rvame: Rbl teen bpec
uocument Hevised: Sept. 21, 2016
�PacMnaalyA7.4
Laboratory receiving samples:
Asheville ❑ Eden❑
Document No.:
Greenwood ❑ Huntersville ❑
Issuing Authority:
Pace Quality Office
Raleigh Mechanicsville❑
Sample.. Client Name: 1 c W0# : 9Z344907
Receipt Prajec
Courier: ❑Fed Ex DUPS ❑USPS Vi;nt
❑ Commercial []Pace []Other: 92344907
Custody Seal Present? ❑Yes No Seals Intact? ❑Yes PTNa
pate/Initials Person Examining Contents...
Packing Material: ❑Bubble Wrap ❑Bubble Bags done ❑ether:
Thermometer:
®IR Gun Ip: _ IS-3492 _ Type of Ice: ]wet ❑Slue ❑None []Samples on ice, coo&ng process has begun
Correction Factor: uib.a r Cooler Temp Corrected (•C): h, Biological'Tissue Frozen? ❑Yes ONO kKIA
Temp should be above freezing to 6'C
USDA Regulated Soil ( N/A, water sample)
Did same nate in a quarantine zone within the United States: CA, NY, or SC (check maps)? Did samples originate from a foreign source lint tionatly.
Dyes Who including Hawaii and Puerto Rico)? []Yesa
[amments/01screp2n
Chain of Custody Present?
1.
Samples Arrived within Hold Time?
❑ ©
2.
Short Hold Time Analysis (02 hr.)?
❑ ❑
3.
Rush Ttim Around Time Requested?
©
4.
Sufficient Votume?
2r,
S.
Correct Containers Used?
-Pate Containers Used?
6.
Containers Intact?
e
0❑
Samples Field Filtered?
S. Note If sediment is visible incite dissolved container
Sample labels Klatch COO?
-Includes Date/TmeAD/Analysis
91
0 El
Headspace in VOA vials (?S-6mm)?
' . _ -- - �......' -�_-• �
Trip Riank Present?
Trip Btank Custody Seals Present?
Yes No _
•_-___•_� --fir
Yes No
❑ 13
Yes No
A
A
l0.
- - -- , , .'Y
CLIENT N9nF1CATtON/RE5OLUTI0N
Person Contacted: I
Comments/Sample Discrepancy:
I Field Oata Required? ❑Yes ❑No
Date/Time;
Project Manager SCURF
Review: _ Date: _ G' > ! 17
Project Manager SRF L44
Review: 41 Date:
Note: Whenerer there is a discrepancy affecting North Carolina compllanee samples, a copy of this form will be sent to the North Caroll na DEHNRCertification office (Le.
Out of hold, Incorrect preservative, out of temp, incorrect containers)
Page 2 of 4
Lk

11�aceAnalyfical
www.pacelabs.com
1
Laboratory Report.
Robert Pawelczak
Domino's Pizza Dist of NC
3100 Waterfield Drive
Garner, NC 27529
Project: Stormwater
Pace Project No.: 92344907
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
Report Date: 06/28/2017
Date Received: 06120/2017
Sample: Retention Pond
Lab 10: 923"907001 Collected: 06/20/17 05:30 Matrix: Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
SM 2540D
Total Suspended Solids
ND
mglL
3.9
06/21/17 13:44
EPA 1664B
Oil and Grease
No
mglL
5.0
06/28/17 06:27
SM 9222D
Fecal Coliforms
3.0
CFU1100 mL
1.0
06/20/17 16:10
SM 4500-H+B
pH at 25 Degrees C
5.5
Sid. Units
1.0
06/26/17 15:00 H6
SM 5220D
Chemical Oxygen Demand
25.0
mg1L
25.0
06/23/17 06:35
ANALYTE QUALIFIERS
H6 Analysis initiated outside of the 15 minute EPA required holding time.
Reviewed by: //=—
Chris Derouen
[phone]
[e-mail]
Raleigh Certification Ibs
6701 Conference Drive, Raleigh, NC 27607
North Carolina Wastewater Certification*: 67
Charlotte Certification IDs
9800 KinceyAve. Ste 100, Huntersville, NC 28078
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification M 12
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
FioridalNELAP Certification #: E87648
Massachusetts Certification*: M-NC030
North Carolina Drinking Water Certification #: 37712
Eden Certification IDs
205 East Meadow Road Suite A, Eden, NC 27288
North Carolina Drinking Water Certification #: 37738
North Carolina Bioassay Certification #: 16
North Carolina Drinking Water Certification #: 37731
South Carolina Certification #: 99006001
FloridalNELAP Certification #: E87627
Kentucky UST Certification #: 84
VrginiaNELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
VirginiaNELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
VirginialVELAP Certification #: 460025
Page 1 of 4

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111OW-125mLPlastk Unpreserved ( NIA) (Ci•j
BP3U-250 mL Plastic Unpreserved (N/A)
BPZU-SOOmLPlastic Unpreserved(N/A)
"~
BP1U-f liter Plastic Unpreserved (N/A)
f
BP35.250 mL Piastic H2504 (pH < 21 (Cl •)
BP3N-250 mL plastic HNO3 (pH < 2)
BP3Z-250 mL Plastic 2N Acetate & NaOH (>9)
OW-250 m L Plastic NaOH (PH >12)(CI•)
_
WGFU-Wide-mouthedGlassjar Unpreserved
AG1U-1 liter Amber Unpreserved (N/A) (Cl-)
�.
AG1H-1 Her Amber HCI (pH c 2)
AG3U•250mLAmber Unpreserved (N/A) (CI•)
AGU-1 liter Amber H2SO4 (pH < 2)
A133S-250 mL Amber H2504 (pH -c 2)
AG3A(DG3A)-250 mt Amber NH4CI (N/A)(0-1
DON-40 mL VOA HCI (N/A)
VG9T.40 m L VOA Na2S203 (N/A)
VG9U-40 mi VOA Unp (N/A)
OG9P40 mL VOA HIP04 (N/A)
VOAK (6 vials per kit)-5035 kit (N/A)
VIGK (3 vials per kit)-VPH/Gas kit (N/A)
MT-125 mL Sterile Plastic (N/A — lab)
SPZT-250 ml.Stedle Plastic (NIA —lab)
r
8P3A-2S0 mL Plastic (NH2)2SO4 (9.3-9.7)
Cubitainer
VSGU-20 mL Scintillation vials (NIA)
GN

r
° ^ RECEIVED
NCOENR O C T 28 2016
Stormwater Discharge Outfall (SDO) CENTRAL FILES
Qualitative Monitoring Report DwR SECTION
For guidance of filling out this form, please visit: hitp://portal.nedenr.orJweb/%�'q/%VS/ a/np(lesstiN,#tab4
Permit No.: NICI I—l_l_I_I_I_I or Certificate of Coverage No.: NIC/G161Q�I,�hST
Facility Name: bow/ ,UdS P1 ZZ0. . 4 L C
County: I)Uci ke Phorie No ' ' 9 / `S- F
Inspector: Ve iKJ =1 4
Date of Inspection: 17/ag 1leP
Time of Inspection: O: 0O -,
Total Event Precipitation (inches):
Was this a Representative Storm Event? (See information below) dyes ❑ No
Please check you r permit to verifj, if Qualitative Monitoring mast he peifori ie— duririg a representative
storm event (requirements varl').
A "Representative Storm Event" is a stor►h-event that ffieasures`greater than O.i inches'of rainfall and that
is preceded by at least 72 hours (3 days) in which no storm event measuring greater than 0.1 inches has
`occurred. A single storm event may contain up to 10 consecutive hours of no precipitation.
By this sigt atur i cey[ify is report is accurate and complete to the best of my knowledge:
(Signatn o Permittee or Designee)
1. Outfall Description:
Outfall No. 1 S cture (pipe, ditch, etc.)
Receiving Stream: W h t� t7)ay- c -e e
Describe th indufSStrial activities that occur within the outfall
rtn�i: ��GT�
2. Color: `-Describe ihe`coif or df the discliaige us
(light, medium, dark) as descriptors: ifkp�� �
16nj f 1'.; 0 -?a "3 j
44
area: e}Z;
ingbasic'colois (red, brown, bide etc. -)'and tint
%A-Q
3. Odor: Describe an distinct odors that the discharge may have (i.e., smells strongly of oil, weak
chlorine odor, etc.): �-
page t :of 2
S WU-242-20120613

4. Clarity: Choose the number which best describes the clarity of the discharge, where I is clear
and 5 is very cloudy:
t 2 :<<:3 4 5
5. Floating Solids: Choose the number -which best describes the amount of floating solids in the
stormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
1 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
2 3 4 5
7. is there any foam in the stormwater discharge? Yes 09
8. Is there an oil sheen in the-stormwater discharge? Yes
9. Is there evidence of erosion or deposition at the outfall? Yes No
I-
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may
be indicative of pollutant exposure. These conditions warrant further investigation.
•
Page 2 of.2
SWU 242-20120613

SEMI-ANNUAL STORMWATER DISCHARGE MONITORING REPORT
for North Carolina Division of Water Quality General Permit No. NCG060000
Date submitted L�4 / &
CERTIFICATE OF COVERAGE NO. NCG060o2 3
FACILITY NAME U
COUNTY
PEkSOWCOLt ECTINGISAMPLES
LABORATORY ?~'aC�e-_N� _a Lab Cert. # L Z
P,a.rt,,A:,Stormwater: Ben chmarks:andiMonitoring.Res ults.,,,
SAMPLE COLLECTION YEAR
FACILITY ACTIVITIES INCLUDE (check all that apply):
❑ use/process meats ❑ use animal fats/byproducts
DISCHARGIW6tb SALTWATERS? ❑YES KJNO
PLEASE REMEMBER TO SIGN ON THE REVERSE 3
„Toralfevent rainfall or ❑ No discharge this period3
Oiitfall IVa.
.,
66—le Collected,'`
mo/,dd/,yr.r:
TSS;€.,UA-
J"­.t� pW, `'� k
,.5tandarcl units
COD;
yfi:; . mg/LLB
xn°
Oil and Greases
:a, w�mg/�L �4
` Fecal Colifotm ,
Colonies "er iD0 nil
P.
"' Enteroeocciy,
NColonies, er,100imi�. a
a,'-
-..- .I
t
F,AOol�or,�50�
- T. ..6, r,:
JMithin 6.0';9.0
�_.rdye,
�7— 40Ig,
I , 3C
fe
. MIR 1000_. ��.�:. �
e
, f.r.
• T_ .. .{ 1
t' qlr2 C,
VV
!•
I
�(f, Vi
s.F",t' 1�+:f::ya'�0*j
•, ',t�1 ��•ia-
'A,.s ,•
'�' ,i�' r:-. ,`�
S
1 Only applies to facilities that use/process meats. _ CENTRAL FILES
ZThe total precipitation must be recorded using data from anion-site,rain.gauge. .. DWR SECTION
a For sampling periods with no discharge at an outfalls. You must still submit this?discharge�monitoring report with a checkmark here.
"See General Permit text, Table 3, identifying the especially sensitise receiving;water dassificationswhere the more protective benchmark applies.
Did this facilityperform Vehicle Maintenance Activities'usiii ``r*'i "" �t" 55,` a11'oris of new motor oil per month? es no
P g,. ,.- t. .. g P ❑Y ❑
Part B: Vehicle, Maintenance. Area Mon itori.ng,Results: only for facilities averaging > 55 gal of new motor oil/month.
OutfaYl No'�
le Collected;
MR107,5117,yr ."
Oil anc! G.rease,�
.- . ml,"
fT55;
m /L g , }..
1^� pH;�SFIaa
Standard units.y
F New MotorC►ii Usage; '
.. Annual average gal/Jmo
gBencli a
1U_Ujor50rF
Only applies"t6'facilities that;use/process meats.
ZThe'total'precip:1tation mustfi�e recorcJed'`using`tlafa'from an on=site rain gauge.
3For sampling:peridds,%i ith 6o disciia'rge';af-an `outiaiisl you mus't�st if�'subhit'this discharge monitoring report -with a checkmark here.
4See°.General Permit'text'.:Tablei3,".identifyingTtti6lespecially sensitive receiving water classifications where the more protective benchmark applies.
(if yes, complete Part B)
S W U-249
Last Revised: October 18, 2012
Page 1 of 2

*FOR'PART,A,AND,PART4,B:MONITORINGoRESULTS:
' `A'BENCHMARK"EXCEEDANCEIRIGGERS'Tl9 1 REQUIREMENTS: -SEE PERNIIT'PART II SECTIONIB.
• 2`EXCEEDANCES 1N'A'ROW�FORFTHE'SAN1EAR 'PAMETER AT7HE SAME OUTFALLTRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• ' TIER;3:, HAS YOUR-FACIL-ITY,HAD,4�OR•MORE-BENCHMARK EXCEEDENCES FOR THE -SAME -PARAMETER AT�ANY ONE OUTFALL? YES ❑ NO ❑
IF•YES,'HAVE YOU -CONTACTED THE-DWQ REGIONAL -OFFICE?, YES -❑ NO ❑
REGIONAL OFFICE CONTACTNAME:
Division{'of!-Xfater C►uality
Attn: D,WQCentral;Files
A617 Mai[Service-Center
.•Raleigh;.,NC -.27699-1617
IL
YOU MUST SIGN:THIS CERTIFICATION. FOR' A'NY71VF691WA-T101V REPORTED:
" I certify, under penalty of faw, that this document.and all attachments were prepared under my direction or supervision in accordance with a
E„system designed to assure thatsqualified,personnel,proper;l,y,gather-and evaluate-the•information,submitted. .Based.on my inquiry.of-the
-^x7zrr ell J 3O"yk ,. ., F' a' 7'4.e3�` f '! i. F �5 �i. ': t-.
person±or�•persans.who manage -the system; orb ose�persons;diresctlVresponsible,far gatheriiig.the information;.the=infoirmationesubmitted is,
t hi est of;rriy know edlgeai d bel�ef,arue, accurate;.andlcomplete. I am aware that there are significant penalties for submitting false
information,; incl prison ment for knowing'violations." -
{
(Stgnat :Perrnittee)'
Additional copies of this form may be downloaded at: http://portal.ncdenr.org/web/wq/ws/su/npdessw#tab-4
S W U-249
Last Revised: October 18, 2012
Page 2.uIi2,, r

CHAIN -OF-CUSTODY ! Analytical Request Document
r" The Chan -of -Custody is a LEGAL DOCUMENT. AU relevm l Wis must be completed eom ntety,
i
r. e
Aftf
ftol., M
E
wAftwow
SAMPLE ID
AR
OT
i
7
4
■■■■■■■■■■■■
■■■■■■■■
■■1■■■■■■■■■
■■■■■■■■■m
■■■■■■■■■■■■
■■■■MINE■■■■
■■■■■■■■■■■■
.r:-
reP•.nL'
'
■■■■■■■■■■■■■■■■
■■■■■■■■■N■■■■■■
■■■■■■■■■■■,■■■■
■■■■■■mmon■■■■■s■■
■
■■■■■■■■■■■■■■o■■■■
LOW
■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■
�■
-
ri:
.
q•
.. - •=y:'
'.'a
its:
_
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'^pN. :Y!�.
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-•.::'
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�,aceAnWtal*
Document Name: Document Revised: May 24, 2016
Concildon Upon Rece t(SCUR) Page I of 2
Document No,: Issuing Authority:
F-RAL-CS-001-Rev.04 Pace Raleiah Quality Office
I M'36, Intpnal I Ica rlui v
ConditionClient Name:
N : 92314165
,
iProeec
Courier. d ExP5
❑U5P$
Client
l
IFI
II
I
I
i
II
II
I'�
❑ Commercial []Pace
❑Other.
92314165
:ustody Seal Present? []Yes ONG
seals intact? ❑Yes
�3Np f�n�Q+
i?atrjinnon iais PersExaminfits: g ConLem�iv }„��i`"f � 4
Packing Material; ❑Bubble Wrap
❑Bubble Bags done
❑Other.
Thermometer: T1SOS
Type of lee: mWet ❑Blue []atone ❑Samptrs on ice, eoor'mg process has begun
Correction Factor: 0.04C Cooler Temp Corrected )•C(: 23 'Ij I
Biological Tissue Frozen? []Yes []NO N/A
Temp should be above freeiing to VC
to
JSDA Regulated Solt (P NIA, water sample)
)id samplesprigInate lil a quarantine zone wttNn the Unod States: Ck NY, or SC (check maps)? old samples originate from a foreign source Pn atlonally,
]Yes No Including Hawaii and Puerto Rico)? []Yes JOW
Comments/0
:hale of Custody Present?
dyeS
ONO
N A
1.
tamples Arrived within Hold Time?
yes
No
N A
2.
short Hold Time Ana s )42 hr.)?
Yes
ONO
❑N/A
3.
Push Turn Around Time Requested?
hyss
No
ONIA
4.
iufficient Volume?
216,
ONO
ONtA
S.
:orrect Containers Used?
�tes
ON.
❑NfA
6.
-Pace ConWners Used?
C es
nN.
ONfA
:ontalners Intact?
is
LIM
❑N A
7,
lam les Field Filtered?
13Yes
QNo
NIA
S. Note if sediment Is visible In the dissolved container
;ample labels Match COC?
gfY@l
❑Na
ON/A
9.
-includes Datefrime/iD/Ana is Matrix:
old containers needingadd/base preservation have been
10. wawa
:hecked?
es
(JNo
©N/A
all containers needing preservation are found to be In
aompidance with EPA recommendation?
HM4W .s
'HNO.,, H2SO4, HCI<2; NaOH * Sulfide, NaOH>12 Cyanide)
s❑No
V
❑N/A
w ��
ixceptlons: VOA, Coilform, TOC, Oil and Grease,
AO/8015 (water) DOC-LEHg
es
171N.
A
Mi01 V—P"
;am ies checked for dedlrorination?
"
Na
N/A
11.
dead ace in VOA Vials >5-6mm)?
Yes
ONo
A
12.
rrlpBlank Present?
❑Yes
ON*fA
13.
rrip Blank Custody Seals Present?
❑Yes
ONoA
Pace Trip Blank Lot p (if purchased c
CLIENT NOT'IFICATION/RESOWT1ON
Person Contacted: Date/Time:
Comments/Sample
Discrepancy:
Field Oats Required? QYes ONO
Project hUnager SCURF Review: Date: g/;?y
i
Project Manager SRF Review: Date: ZI-0
Note: Whenever there is a discrepancy affecting North Carolina compliance samples, a copy of this form wig be sent to the Nortfi CaWlina BEHNRCertiticatton Office (Le.
Out of hold, in erect preservative, out of temp, moorrekx conulners)
Page 2 of 3

aceAnalyfical
www.pacetabscom
i
Laboratory Report
Robert Pawelczak
Domino's Pizza Dist of NC
3100 Waterfield Drive
Gamer, NC 27529
Project: Stormwater 9129
Pace Project No.: 92314165
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
(919)8344984
Page 1 of 1
Report Date: 10/14/2016
Date Received: 09/29/2016
Sample: RETENTION POND
Lab ID: 92314165001 Collected: 09/29/16 10:30 Matrix: Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
EPA 1664E
Oil and Grease
ND
mg/L
5.0
10/07/16 06:41
SM 9222D
Fecal Collforms
2000
CFU1100 mL
1.0
09/29/16 16:25
SM 2540D
Total Suspended Solids
ND
mg/L
3.0
10/03/16 22:08
SM 4500-H+B
pH at 25 Degrees C
4.7
Std. Units
1.0
10/10/16 15:30 H6
SM 5220D
Chemical Oxygen Demand
47.0
mg/L
25.0
10/14/16 02:35
ANALYTE QUALIFIERS
H6 Analysis initiated outside of the 15 minute EPA required holding time.
Reviewed by: /�
Chris Derouen
[e-mail]
Raleigh Certification IDS
6701 Conference Drive, Raleigh, NC 27607
North Carolina Wastewater Certification #: 67
Charlotte Certification IDs
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
Asheville Certification IDS
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
Massachusetts Certification #: M-NCO30
North Carolina Drinking Water Certification #: 37712
North Carolina Bioassay Certification #: 16
North Carolina Drinking Water Certification #: 37731
South Carolina Certification #: 99006001
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
Vrginia/VEL4P Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 9903000i
Virginia/VELAP Certification #: 460222
Page i of 3

CERTIFICATE OF TOW%FACILITY NAME o
COUNTY
PERSON'C'&LECTING+59
LA80Ri4'>'ORY_%Ce
SEMI-ANNUAL STORMWATER:DISCHARGE MONITORING REPORT
for North Carolina Division of Water Quality•General Permit No. NCG060000
Date submitted 2 O I G
,GE NO. NCG06 Dom? 36 SAMPLE COLLECTION YEAR
.f`n►0 S Z,4 L L FACILITY ACTIVITIES INCLUDE (check all that apply):
❑ use/process meats ❑ use animal fats/byproducts
MPi,ES - , e- ",) DISCHARGINGITO SALTWATERS? []YES �O
0k V� f-cG•x -- Lab Cert. # - w'�7
PLEASE REMEMBER TO SIGN ON THE REVERSE 4
Part A:,Stormwater;Benchmarks, and Monitorine,Results,, .:�,,, .:r , .r ,.,., ,Total,event rainfall Z or n No discharge this period
aQutfaII Na.:>`
._� . _, T
Sample Collectetl,
mo/,dd/�yr„
TS5,.COD;andss"Grease`;
mg/,L�,5tandartl
units�;mg/;L�.
.d�N`4.�'•..$3df.,
.,�a
�aK
<mg/L:•.: _
` tFecaliCollform ,., ;
I. -.. 3,.s[';:�'#hM"wu:-..
k,,iColani.eslper,100,m1 ` -
IEnterococci,;
��' ::�• .-..�"4.�.'; -.:r..
, Goloniespeoo,mi,
.- :�-
,'Benehmark'�
_ ".
• 1
f 100rr�5d _�'i
.,..-. � � €
P �Withina6 0.-:9 0
i.-i1
:' a 21)°^ . F
may:; Jaw,
$ i1
: ,.c1D00x ,
A -.1
a. 50d
i717eI
I.W �Z y vi
.dF l
GIsr
/-r-
1L
r �': ...i.iis i�F.;''�,.'
'.i ';� `'
ri �• .lift, {'•
i r
.y Z: �. 'is
- _ 1P to,(
. K- .'-i ... ..
'7�:. `�15• -`1:"i .F••'4.�-�;/h
'. •., -' _ f 1� �7s.
i #'.t4^'� istiii"'��'�f
`..1~e�..4>' r"!"�•Lti1e.�
5 "t:' ti� �'s.:
,_�',. 't.� r .. L_i
-. ` 4'
_
Only applies to facilities that use/process meats.
zThe total precipitation must be recorded using data from anon-site�rain.gauge
3 For sampling periods with no discharge at any outfalls. You must•still submit this'discharge:,monitoring report with a checkmark here.
See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
it S. •its. • '7,e` . ;. . ;tir r, u
'" ""' ` `,'' ``' - ' ,w + `�' a
Did this facility
perform Vehicle Maintenance Activitie4kuSing'iiiore,than_55 gailans.of new motor oil per month? ❑ yes ❑ no
Part B: Vehicle Maintenance Area Monitorine,Results: only for facilities averaeine > 55 eal of new motor oil/month.
'Outfall No.
4+,
=YrAec
,
11-9
Qamg/
r �
_
a?�pH; -'
StanadneWin14
NAe9'w1' Mo'Kt'ar:0'lhUiysa. ge,
$amo
Annuavp-A
30tir, t
= l00 ar'506:Or"
9t0
(ides, complete Part B)
,: t
'Only appiie's'td.facilities.that:use/proces-s meats: ' " -
2 1 14 Ca::'. =.. �:•.... �,''..:C - i fsd .' .ci. ;I"-'.!M'C� �� r- w, t.. f.c ... 11 i�'t7 t •� f1 - ... ._l '.� „i rI
The total precipitation mbsrbe recorded using data from an on -site rain gauge. -
3 i"For sam lingPeriods'withriofiscarga of aoalsl,�j utflyou mus stillsubmitdhar a moAif o ri ng report, with a check mark here.
4See'General,Permit'tt?xf; Table�3,".iiieritifyingitR61especially sensitive receiving water classifications where the more protective benchmark applies.
SWU-249 Last Revised: October 18, 2012
Page I of 2

*FOR PART A AND,PARTiB:MONITORING -RESULTS:
+ ' 'A'BENCHMARK'EXCEEDANCCU fG6ERS`TIER'1 REQUIREMENTs:-sEE PERMIVIDART II SECTION`S.
• 2 EXCEEDANCES iN"A'ROW'FOR'THE'SAME`PAR'A: /lE7ER AT THE SAME= OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART EI SECTION B.
- =• TIER•3:� HASNOUR�FACIL-ITY HAD 4.OR-MOR&BENCHMARK EXCEEDENCES FOR THE -SAME -PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑
IF -YES,: HAVE Y0U'C0NTACFED-THE-DWQ REGIONALOFFICE?-- YES •❑ NO ❑
' REGIONAL•OFFICE-CONTACT �NAME: "
'M"ail air origJrraL`arrd:one cony'of tJiJs'DMR inclu[IJrip all "No DJscliarpe"reports, wlthln"30`daysof receipiof the 'results (or at end o
monitoring pe' iod'in the case of "No Discharge' , epoid).to:
74
Ij
• `� ° 'DM' of of`Wa`ter Quality
,Attn: DWQ Central -Files
r 1617 Mali,Service.Center
c•. 41 Raleigh; NC .,27699-1617
YOU MUST SIGN'THIS`CERTIFIGATION'FORANY INFORMATION REPORTED:
-1 _certify, under enalt of law,;that this document and all attachments were re ared under;m direction or_super�isipn-in acco.rdance;with a
Y p Y _ p p
system designed to assure that qualified^personnel p.roperl,y.gather and ev,aluate,the,,information,submitted.. Baseci,on.my_inquir.y.,of_the
person or persons who.manage the, system; or those persons.directly responsible for gath&ing•the,information; the- information submitted is,
to the. best of#my k'nowledge and befief,.true, accurate; and'complete. I am awar6,that there are sigri,ifieanVpenalties.f6r s6brriitting false
1 infarmat'ion,-inc� the;possibility,afAfines,.and-�i•mprisonment for knowing•violations. -
- •, F, U- ,- L.,,..
[SI afar 'of4P.ermitteeyc
Additional copies of this form may be downloaded at: http.,//portal.ncdenr.org/web/wq/ws/su/npdessw#tab-4
SWU-249 Last Revised: October 19, 2012
Page 2. of 2-p

a
owAr�9Q�
co r
o -c
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Permit No.: or Certificate of Coverage No.: NIC/GIQ -35-L1 1_I
Facility Name: e0 "✓ 1%; �� '
County: ' ►q. Phone No. U �G L'' 3
Inspector:
Date of Inspection: /c .4 6-
By this signatye, I certify that this report is accurate and complete to the best of my knowledge:
(Signature of Pe-nnittee or Designee)
1. Outfall Description
Outfall No. Structur pi e' itch, etc.)
Receiving Stream:
Describe the industrial activities that occur within the outfall drainage area: M ,A ;
2. Color
Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint (light, medium,
dark) as descriptors: C t e et ✓'
3. Odor
Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor,
etc.) /VU N e - - — -
4. Clarity
Choose the number which best describes the clarity of the discharge where 1 is clear and 10 is very
cloudy:
1
2 V 4
5 6 7 S 9 10
Page 1
S WLT-242-020705

r
5. Floating Solids
Choose the number which best describes the amount of floating solids in the stormwater discharge where
1 is no solids and 10 is the surface covered with floating solids:
2 3 4 5 6 7 8 9 10
6. Suspended Solids
Choose the number which best describes the amount of suspended solids in the stormwater discharge
where 1 is no solids and 10 is extremely muddy:
1 3 4 5 6 7. 8 9 10
7. Foam
Is there any foam in the stormwater discharge? Yes oNo
8. Oil Sheen
Is there an oil sheen in the stormwater discharge? Yes CNo)
9. Deposition at Outfall
Is there deposition of material (sediment, etc.) at or immediately below the outfall?
10. Erosion at Outfall
Is there erosion at or immediately below the outfall? Yes oNo
11. Other Obvious Indicators of Stormwater Pollution
List and describe
Yes DNo
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, deposition or erosion maybe
indicative of conditions that warrant further investigation and corrective action.
Page 2
SWU-242-020705

WA�4
r
o -c
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Permit No.: NICIIC'll G'I c=•1 E �l / or Certificate of Coverage No.: NIGG/Cs� Ohl �l 1 I
Facility Name:
County: K& ^Phone No. 4 ' c'CJ -61 V3 -
Inspector:
Date of Inspection:
By this signatvfe, I certify that this report is accurate and complete to the best of my knowledge:
(Signature of� or Designee)
1. Outfall Description
Outfall No. Struc i e' itch, etc.)
Receiving Stream:
Describe the industrial activities that occur within the outfall drainage area: ,"A
2. Color
Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint (light, medimn,
dark) as descriptors: (C i ✓'
3. Odor
Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor,
etc.) !:: r
4. Clarity
Choose the number which best describes the clarity of the discharge where I is clear and I0 is very
cloudy:
71
1 2 4 S 6 7 8 9 10
Page 1
SWU 242-020705

5. Floating Solids
Choose the number which best describes the amount of floating solids in the stormwater discharge where
1 is no solids and 10 is the surface covered with floating solids:
if 2 3 4 5 6 7 8 9 10
6. Suspended Solids
Choose the number which best describes the amount of suspended solids in the stormwater discharge
where 1 is no solids and 10 is extremely muddy:
1 (D2 3 4 5 6 7. 8 9 10
7. Foam
Is there any foam in the stormwater discharge? Yes oNo
S. Oil Sheen
Is there an oil sheen in the stormwater discharge? Yes GNo
9. Deposition at Outfall
Is there deposition of material (sediment, etc.) at or immediately below the outfall? Yes No l
10. Erosion at Oatfall
Is there erosion at or immediately below the outfall? Yes oNo
11. Other Obvious Indicators of Stormwater Pollution
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, deposition or erosion may be
indicative of conditions that warrant further investigation and corrective .action.
Page 2
SWU-242-020705

SEMI-ANNUAL STORMWATER DISCHARGE MONITORING REPORT
for North Carolina Division of Water Quality General Permit No. NCGO - 60boo
Date submitted
CERTIFICATE 00 COVERAGE NO. NCG06_Q
FACILITY NAK4E'�ho,,,;.x*S!�);2—r-o, 4J_C_
COUNTY, W(XKA-
PERSON' , COLLECTINGiJAMPLES
SAMPLE COLLECTION YEAR
FACILITY ACTIVITIES INCLUDE (check all that apply):
0 use/process meats [] use animal fats/byproducts
EAj6P"Gi'Wd1tb SALTWATERS? EJYES [aNO
1afC_e'rt_. #
0 4 2D6 PLEASE REMEMBER TO SIGN ON THE REVERSE 4
CENTRAL FILES,,,,,. info 12
F,P;,t.4:,$tc!rmwater,penchmarks.and: Monitoring,Results.,, _.,..,,r0.WR APP-Irtr%,�. .Tota event ro or D No. discharge this period
0ijtfSIbNd';
74 �L_11­ ��; I
4
ffijj 610 ec e
;,;mo
"TS
IR
5w�
�W
'0
;AW
a I units,,
! lui
4
m
_nd[Gr'e­a;s'e',,,.,111,
�rnv,,L e�,­
FecallColifornil,
V.4
colonles4i6r;,
�Eh
nn iml
MMI, 1 7A
60 1�n�
0
7,77,
T,'j tTifx 1
7s 7q71-)_7e_k2-!7-,
3
4,
Z: Tn
Only applies to facilities that use/process meats.
The total precipitation must be recorded using data from a6,,on-sit6�rain gauge.
3
For sampling periods with no discharge at gU outfalls. You must -still submit this-discharge,monitoring report with a checkmark here.
': ' , 'r . :,,., .. _. I '- - - See General Permit text, Table 3, identifying the especially sens-itive' receiving 4ifications where the more protective benchmark applies.
it 3- + I i ',? " , . " :"
Did this facility perform Vehicle Maintenance Activitiqusing'.ffid(effiah 55 gallons of new motor oil per month? 1:1 yes Ono
Part B: Vehicle Maintenance. Area Monitoring.Results: only for facilities averaging > 55 gal of new motor oil/month.
F;'Ottfall€NoSample
Collected ,
*4
dillriliBtlre'
,Y&Vojdd7fr.
A Hi'New
S.tan"da�r units',,
jM6tn�50il_tUsage
_'Annuap v ragjijal mo;..
,-..
.10
I Only apolie9'M -fa6lltiei-`th6i,ds6ffir6c6s's fn6its-
The'total'precipitatio'h'must'be e&corde'd"dsl'Q"Wia fr6m' an on -site rain gauge:
3
For sam 'plin"g','p'e-riods,w"ith,-6'0'dis'6ti6*egL-"ai-'a"�U-166iPalls!rio"tTm"Ust4st-ii(,sUb'M'Ct-i6is"discharge'mo hi oring report -with a checkmark here.
4See,General 1?6rmittextu-,Tj 6le?3,-idi�6tifyifigtt�6le—s-ogc-i5ily sensitive receiving water classiflcations where the more protective benchmark applies.
,'
ow
(if yes corn f iete�Part B)
AO=tk
LOP
Wo
SWU-249 Last Revised: October ][8, 2012
Page 1 of 2

"FOR PART°A• AND,PART+B`,MONITORI NGFRESULI'S:
• '•A-'BENCHMARk EXCEEDANCE-TRIGGERS{Tiek'1 REQUiktMENTS.-Stt PERMIVPART it SECTION''B.
• 2`EXCtEDANdE lKW' 'A ROFOR�_THE'SAME'PARAiVIETER AT TH;E SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS, SEE PERMIT PART II SECTION B.
- • " TIER-3 •HAS-HAS.4.OR-MORE-BENCHMARK EXCEEDENCES FOR"THE-SAME-PARAMETER"AT ANY ONE OUTFALL? YES ❑ NO ❑
IF -YES,, HAVE YOU CONTACTED -THE DWQ REGIONAL OFFICE? YE5 ❑ NO ❑
-REGIONAL-OFFICE-CONTACT-NAME:
IVIaiI an oriWOW *an d."orie°cb o a Dschr �e}&results or at end
_aue0'oeto o
monitoringpe'riad'in the,rdse of "No Discharge"-r_epo_r_tJ._ta:
, S
' -Division of',Water' Quality
Attn: DWQCentral-Files
1517 Mai[Service.Center
c!. -1, Raleigh; NC �,27699-1617
YOU NMUST SIGN-THIS'CERTIR TION FOR•ANY'INFORMATION REPORTED:
"I certify, under penalty of law,;that this ddcument and ail attachrnents were prepared under:my direction or.serperv_ision:in accordance -with a
system designed td•assure_ that'qualified�,personnel properly gather and evaluate -the information, submitted..Based.on my inquiry,of-the
�person-or persons who manage"th' i'y! ems or.�those,persons directly responsible for'gath&Jn&the info'rm`ation, the,information submitted is,
•,,., s ti j, .. ;-,`yA., ..-.,'t - ^.,•:rra�e'-^w •'A {�»-•rt
to the best of, my..knowledgeaeid belief ,true,'accurate; ahclzomplete. I am awar..0jhat.there are sfgnificant•,penalties for submitting false
I information,:i'nc�ding,•thetpossibility.of.-fines and -imprisonment for knowing•violations.
.-:(Date)
••LIt.}1 "E• � � �'-.• a h• -• _. ! Ff." � - , -� � i ter- '
a - '
Additional copies of this form may be downloaded at: http://portal.ncdenr.org/web/wcL/ws/su/npdesswgtab-4
SWU-249 Last Revised: October 18, 20I2
Page 2, alf 2� 1 -0

WDENR `
Stormwater Discharge Outfall (SDO)
Qualitative Mo5nitoring 'Report
For guidance on filling out this form, please visit: htip://portal.ncdenr.orJwcb/wy/ws/su/npdcssw#tab4
Permit No.: NICI_I_I 1 1 1 1 1 or Certificate of Coverage No.: NICIGIOI & AQ?IJI­isV_
Facility Name: i r -KZ
County: , s, F„ .. t • "Phone No ° gL9' '% 7g
Inspector: K 4&L
Date of Inspection: o%�7/L_< _ --
Time of Inspection: Wspqrn-
Total Event Precipitation (inches): IN i'j
Was this a Representative Storm Event? (See information below) R"Yes ❑ No
Please check your permit to verify if Qualitative Monitoring inust be performed'duririg a repies-e'ntat�o
storm event (requirements vary).
A "Representative Storm Event" is a storrii event that meastiies°greater than 0.'1 inches"of raiiifail an '
is preceded by at least 72 hours (3 days) in which no storm event measuring greater than 0.1 inches has
i
occurred. A single storm event may contain up to 10 consecutive hours of no precipitation.
By this'
n e, I certify that this report is accurate and complete to the best of my knowledge.:
—1/ .7.—.009,
(Si tur f-Permittee or Designee)-
1. Outfall Description:
Outfall No. _.- -1 - Structu
Receiving Stream: Oe
N
-(pipe, ditch etc) I Ret" owl -} Ow1j
Describe thp�}j ind strial-activities that occur within the outf l drain ge area: tiz•
MarJu.ireG r..rcpit . U1�41�¢.�+de+tSQ11Jt i[A.r
.°.f. •'4f. '�}t .t-.' Tc. :�+'. s' 'x .`t ;>'. s�:' , .i ._ 3S11
2. Coloi-c Describe the'color of the di charge usin basic tors (red, brown, blue, etc:) and tint
(light, medium, dark) as descriptors: IN 0.
3. Odor: Describe an}}�� distinct odors that the discharge may have (i.e., smells strongly of oil, weak
chlorine odor, etc.): /� 7.A
,-Page rof 2
SWU-242-20120613 '' C. `'

4, Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear
and 5 is very cloudy:
2 3 A 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stormwater discharge, where l is no solids and 5 is the surface covered with floating solids:
l 3 4 5
6. Suspended Solids:, -,Choose the,number-which best describes the amount of_ suspended solids in
the stormwater discharge, where I is no solids and 5 is extremely muddy-
1 3 4 5
7. Is there any foam in the stormwater discharge? Yes No
S. , , Is there an oil sheen in the stormwater discharge? Yes no
9.. Is there evidence of erosion or deposition at the outfall?.
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Yes No
i
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may
be indicative of pollutant exposure. These conditions warrant further investigation.
Page 2.of.2
SWU-242-20120613 ,J .

o
CHAIN OF:CUSTODY!j nak ticalRequest;Document
The, Chain 6f Ci�lody ls.a LEOAL DOCUMEcc
NT. Ail rolovanl fields must be`aomplolod seaurataly.
aCe."fytical -
wixr,pacd� br.caao'.
Swbun A: SrcBon B
Sodlon C
Pepa
ct
R"uNadClknl tnfomuVom - R"6WIr d ProJW W"ngoa:-
'.' hvvolm Irdarnsadon•.-
{> Report
To:
Atlontforr •
CJ'� r�S � .
s,
J. L./,;,!t t
REGUl ATORY`AGEKCY:
Atltlroix:
it : NPDES 'lr7 .GROUNDWATER," r--ORINKING,WATER '
1..
. UST. )5 RCIiA
r. '. OTHER ,
•I'
�x � ,s a?!visa
Nome -
--
race __
-
.,
Ragwrrted Due DatorrAT - . Prrlo4
Numbs' �-
-
pa Prcm 9;
ST'ATL
ueStad-Analyels'FiltaMd
(YIN)
E
yf
Sec1{on�D ! 1. ' - Mitl1�C COdej�
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R�i�IiWNYldoryl4r rM11iRR 1 (�lY]!1 1
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Document Narrje SSatrtpis Condttlon Upon
Rene# t4 ,i
Docume f Revised May t5 2415
Pa 2"
l B aI
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ei of _
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F_RAL'-CS=EJOi;'rev,l33;;
Pace ah Quafit :Office_ _
is'for lnternai Use Only
v
C!#ert Name
it's �sAt
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Packing lVlaterta] � Bubble Wrap t3 � ags r� tJone0 xxQiherx � r
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61
Comments , ;•: :a
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7, h`
Chen of Costaly Filled`out
es ,LiNa C7WA
�
2
, .. -
Chairi`ofCuslod Ratin ulshedi
M Yes;ONo durA
3 ..-.. ..
-:
Sam lar Name; Si natgre,an COC.
Yes_:❑Na ._❑N1A
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Samples Ar+ived'withlri%Flotd=Trme:- . 'g Yee �rio,�:;[Dmlx
5 ,
Shod Hold Time Atiai ' Is ;72h`r Y57
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7�. ,". '
5ufticiant Volume
Yes':E7Hv.j,❑gin
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CorrecE Containers Usedi
Yea fJNn ❑ri%a
9
Pace Conlainers`Used:
= Yea ❑No , ❑wA
-
_
Co`ritafners Intact , .. Yes ❑No_.`.❑NrA
10.
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Frltere twolume received:for Dissolved tests . .. -;_ =Cares ;t No .. WA
14
Sample -Labels match COC
Yes ❑yNo Ok
12
-#nclirdes.dalBitiriaellD%Ana[ sis aiAaGix.
?
-
AU containers naecng preservation have been checked
Yes ❑ No ©NIA
. _ _. .,
13
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AU containers needing presblva6:n'are found to be Iri
oompfranca wtUt EPA recommendation
eucepti . _VOA colifomf, TOC, 08G, Wt [)AU {wafer)
es;. ❑No -
Sam'leschecked 4orechlonnationi . _.
Yee . ❑nro ❑NIA
44:
Iieadspace In V4A Vals'(>6mm :
❑Yes ❑No, , N!A
15.. .
Tr(p Blank Rresent:
❑Yes ❑No Nra'
16.
Trip Blank Custody Seals Present
❑Yes 014o NIA
PaceTrl `;Bki k Lot # if p6r6ase6}:
<... .....
Citent Hatrficationl Resolution Field [3ata Re ulred7 Y ! N
Person Gontacted:, o4i wnjna:
AM I I Al Al
SCURFISRF s
iewew- n , wog . 9273513
Note. Whenever There Is a disaeparacy affecting Nwih Ca tine compliance
sampfes a copy ofthis form wiq La sent t4 the North Ceroilna DEHNFi
Ce"catlon 4fii_ce (I a out of hold tncorrec! preservative out of tamp,
iOc #ecioonta[ners) 92273513 _
i
a
Page 3 of i

1�5a'cmnalyfica(
xswrpatE1365.tam
Robert Pewelczak
Domino's Pizza Dist of NC
3100 Waterfield Drive
Garner, NC 27529
Project: Retention Pond 10127
Pace Project No.: 92273513
Sample: RETENTION POND
Laboratory Report
Pace Analytical Services, Inc.
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
Report Date: 11/05/2015
Date Received: 10/27/2015
Lab ID: 92273513001 Collected: 10127/15 08:15 Matrix: Water
Method
Parameters
Results
Units
Report Limit
Analyzed Qualifiers
EPA 1664B
Oil and Grease
ND
mg1L
5.0
11/05/15 10:37
SM 2540D
Total Suspended Solids
ND
mg1L
2.7
10/29/15 10:04
SM 4500-H+B
pH at 25 Degrees C
5.7
Sid. Units
1.0
11/05/15 13:25 H6
SM 5220D
Chemical Oxygen Demand
49.0
mg1L
25.0
10/29/15 13:40
Sample: RETENTION POND FECAL Lab ID: 92273513002 Collected: 10/27/15 08:15 Matrix: Water
Method Parameters Results Units Report Limit Analyzed Qualifiers
SM 9222D Fecal Collforms 8.0 CFU1100 mL 1.0 10/28/15 14:50
ANALYTE QUALIFIERS
H6 Analysis initialed outside of the 15 minute EPA recommended holding time.
Reviewed by:
Chris Derouen
[e-mail]
Raleigh Certification IDs
6701 Conference Drive, Raleigh, NC 27607
North Carolina Wastewater Certification #: 67
Charlotte Certification IDs
9800 Kincey Ave. Ste 100, Hunlersville, NC 28078
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
South Carolina Certification #: 99006001
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E67648
Massachusetts Certification #: M-NCO30
North Carolina Drinking Water Certification #: 37712
North Carolina Bioassay Certification #: 16
North Carolina Drinking Water Certification #: 37731
FloridalNELAP Certification #: E87627
Kentucky UST Certification #: 84
West Virginia Certification #: 357
virginiafVELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
West Virginia Certification #: 356
virginiaNELAP Certification #: 460222
Page 1 of 3

6 a
a1j
SEMI-ANNUAL STORMWATER:DISCHARGE -MONITORING REPORT
for North Carolina Division of Water Quality General Permit No. NCG060000
Date submitted
t, tt�e's,_;:i+:`"<-, ri:f•? `a ;2F f., •'�. 5. .�i, .•. it .r ,
CERTIFICATE OF' OVERAGE NO. NCG050 2 5 SAMPLE COLLECTION YEAR ;Z C) I S
FACILITY NAME FACILITY ACTIVITIES -INCLUDE (check all that apply):
COUNTY V—)Ct ❑ use/process meats ❑ use animal fats/byproducts
r' _
PERSON`COLLECTINGf5AMPl�S DISCHARGING'TO SALTWATER5? []YES EN'O
L►4BORATORY3('2a Q V4-tC4 IT- Lab Cert. # ' & -
PLEASE REMEMBER TO SIGN ON THE REVERSE 4
P,art:A:.Stormwater,, Bench marks, and; Mon itorine.Results r .. Totabevent rainfall z or n No discharae this oerioa►3
Ou#faIIINo'=
..�,.'
w° h,Yh.
Sam I'e Collected /
Imo/,ddL
x�.
TSSt -
-1,x �
mg/U t�
i '
'' H' ';"'
, k,�
Standard units
' _
~`COD a
k •':c.�.j+ � ,.
;. ?m ,L �y
g/
- ;.Oiltaii'd'Grease� '
;1� •',k' / ..,a,l
�,g ; ; mg/L; ;, . ,-
°Fecal Coliform! .,
?y�..',F. .. � 1-,,:� �
t,._ P ..
Colonies5 er 100jm1
Enterococci•
lr �? J�. 'P��`'��'f5 s....�1,'�
;Colonies er:100im1
aP
pBenchmark�tt"
� ' !'" _ ?
1Qa o 50:w?
Wi#hin fi 0 9t0 ;
..•.�
. t 120 k `r
", .:_,30'
1000? t ...:
i 500
.4 �:.'t .: i. C�li't'�
{�L +.: .••�O 'L{�'a
.�3:. V�' iF ?•.
tr, fls
t
'-it o- r t r
1
„ i- rt 'i✓r .. M�+,Y
'4f�.'... }llrf'.-i!••_-. !4':�-M;'•vJ
:.rt� }F. r :+. f, 1:e�.•t ,�,
t ...f tq 'tit Ik l.�„"
� .. ,a ~ i. 1 t
i
. I - . K!•r: /y
E 7.' 'r
- 't •., ,.',{
:A, -,I- it <� .. 4
} i'l"'. !% '4 r'+. 7
. ',rim;+ t. a' , �Yiy
iri,w 'ty F.3?•
i�•�° 170",•
' Only applies to facilities that use/process meats. ._
The total precipitation must be recorded using data from an?on-sit&rain_gauge.__-
3 For sampling periods with no discharge at any outfalls. You must,still submit,this:discharge+monitoring report with a checkmark here.
See General Permit text, Table 3, identifying the especially sensitive receiving,waterclassifications where the more protective benchmark applies.
er.. v;.,•k 7tom', 1,.'•1 f '�t5 ;'t4'!'� :i
Did this facility perform Vehicle Maintenance Activities using(more`than_ 55�ga116ns of new motor oil per month? ❑ yes ❑ no
Part B: Vehicle Maintenance Area Monitorine,Results: only for facilities averaLrine > 55 Qal of new motor oil/month.
FOutfall>Not
S pie Go`Ilectetl,
2
OilWMIGrease,?
g/Lr" .
'?T55,,_
��;mg/L
pH,
„'Wi
StandardunitsAnnual
aNewlMotorlOil Usage,
t.Ld/yr
average.gal/mo'r
46n6mark:'-
I
�`� 'ti '�
,E.
� 301 ��
�. ... a,
,' 100o`r�50t'"
' Only applies'to facilities that:use/process meats: -
2 , +.4-r"�.'" "''-.^�: C" ii."c�rV 't 4 ki i� !il 3.! :.p. -)`.i lm. 04*6 0'l,.,`;..•:.• . 1
The'total precipitation must'be recorded using data from an. on=site rain -gauge.
3 For sampling?periods with rio discharge` at•pM utfalls you mu t�stillrsulimit,thisydischarge'monitoring report -with a checkmark here.
4See?Ge e'�gl, P.erriiit'text;°s7alle�3;'identifyingitheespecia`Ily sensitive receiving water classifications where the more protective benchmark applies.
=wo.•
room
rM
C2
t;', •
(ice complete Part B)
SWU-249 Last Revised: October 18, 2012
Paee 1 of 2

*FOR PART A AND +PART:B,,MONI70RING. RESULTS:,
• 'A"BENCHMARK.'EXCEEDANCE'TRIGGEAS!tlER-'1 REQU[REI tNTS:'SEE PERMIT'PART II SECTI(jNB.
• 2"EXCEEDANCES•IN°A'ROIIV'FOR THE'SAME'PARANfETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS, SEE PERMIT PART II SECTION B.
`'• TiER-3:- HAS YOUR FACILITY HAD 4 0R MORE BENCHMARK-EXCEEDENCES FOR THE -SAME -PARAMETER -AT ANYONE OUTFALL? YES ❑ NO ❑
IF•YES; HAVE YOU -CONTACTED THE DWQ-REGIONAL-OFFICE?•• YES •0 NO ❑ "
-REGIONAL OFFICE -CONTACT -NAME:
Mail an original and d'ne copy of!ttiis DNIR; includin all "No Dischor a"'re orts;;withrn'30'daM's:'o recer� a +thee Iati results or at end o
g: a p v f w f_
mo_nitor►na.periad in the case`of "No Dischar`pe"-reports) to: { �....
- 'i 'Y, I,ti ,.= '1,Y r+•, .il e., f"•�t.'� • ..ytt �' f :+' !� 1 � .,':�rY• .. �:. .
.... f. �r :Division"of'Water
Quality
Attn: DWQ Central -Files ,
.1517 Mail, Service. Center
:Raleigh; :NC ,27699-1617
YOU MUST SIGN'THIS'CERTIFIeATION FOR.ANY INFORMATION REPORTED: ,
"I certify, under penalty of law,,that this document and all attachments were prepared undermydirection or supervision-in.accordance with a
i s,ystem-designedto assure thaf,qu.alified personnel properly -gather and erialuate_the.information.submitted. .Based,on. my inquiry�of.the
person or.•persons.who.,manage the system; or those persons,directly responsible foregathering theJinformatioh, the�inforrnm tion submitted is,
to the best of,my,knowledge.and belief, trtie; accurate; and,complefe. I am a►niare'that there are=significanf penalties"for submitting false
1-information,Tn din 'the.possibility'of,.fines and;imori'sonment for knowing'violations: ,, '; '',:,. , ' r
• - n ,fa r z/ I t
(Sign-bULrelof-Permitfee)L•l"'
• � - is .. . - is
Additional copies of this form may be downloaded at: http://portal.ncdenr.org/web/wg/ws/su/npdessw#tab-4
SWU-249 Last Revised: October 18, 20i2
Page 2 of 2 � 4-

;aneAnalydcal"
www.paoelabs.com
! 6701 Confereno9 Drive, Raleigh, NO 27607
ph: [phone], fax: (919) b34-6497
NCWW Certa87, NCDW Cert#37731
Report Results To:
Company: � ba. w1 '.3 ;Z�� �
Address: � o0 �n ��►.C_Ld�
-
1 �
Phone: 1O 7 7,?
Chain of Custody W.O.# �aa s0ff
-
Bill To:
Project Reference:
Project Number:
Purchase Order
❑ Standard Report Delivery
Relinquished W
by (s[i#.1IrA
Da6
(
Time
as
Relinquished by (signature)
Reoeiv (signature)
D
7lrne
Relinquished by (signature)
Received by (signature)
Date
Time
Recaipl Conditions (tab LIR Only)
D 4t2'C ❑Temp: °C
Res. Chlorine:
❑ Absent ❑ Present ❑ n/a
Acid presew. <2?
❑ Yes ❑ No ❑ n/a
Base praserv. >127
❑ Yes ❑ No ❑ Na
Page 2 of 3

Document Name: Sample Condition Upon
I Document Revised: May 15, 2015
ZICMna 1Cc?l
Receipt SCUR
Page 1 of 2'
Document No.:
Issuing Author€tias:
F-RAL-CS-001-rev.03
Pace Raleigh QualU Office
t A "Page 2 of 2 Is for Internal Use Only
Client Name. 'l 0
Courier (Circle): Fed Ex UPS USPS Client Commercial Pace Other
Custody Seat on CooledSox Present: yes no Seals intact; jam' yes no
Packing Material; ❑ Bubble Wra Bags None Other j"
Circle Thermometer Used: IR urt N:122085387 ype of IC 1�Ct Blue None � samples on ice, cooling process has begun
IR Gu 065371
Temp Correction Factor: jA00 btra
C
Date and Initials of por: n OKs Irving
Corrected Cooler Temp.: q I C
Biological Tissue 1s Frozen: Yes No wA
t f
check
Temp should be above freezing to VC
Comments:
Chain of Custody Present:
OW
©wA
1.
Chain of Custody Filled Out:
Yee ON.
©NIA
2.
Chain of Custody Relinquished:
A. ❑No
ElNiA
3.
Sampler Name & Signature on COC:
-to, ❑No
]NIA
4.
Samples Arrived within Hold Time:
Yca ONO
ONIA
5.
Short Hold Time Analysis 02hr :
Oyes ZZ.
©WA
6.
Rush Turn Around Time Requested:
OYea No
❑NIA
7.
Sumclent Volume:
es ElNo
OwA
8.
Correct Containers Used;
X"Yes ONO
❑wA
8.
-Pace Containers Used:
9fyes ONO
❑wA
Containers Intact:
Yes ONO
ilwA
10.
Filtered volume received for Dissolved tests
Oyes ❑No
A
11.
Sample Labels match COC:
af
C]NtA
12.
-includes datelt€mellD/Anal s1s Matrix:
All containers needing preservation have been checked.
PTR s ONO
ONfA
13.
All containers needing preservation are found to be in
edYee ©No
17wA
compliance vAlhEPA recommendation.
exoeptlons: vOA, conform, TOG, O&O, MDRO (walor)
�1 Y.l ©No
Samples checked for dechlorination:
Yes ❑Ne
❑NIA
14.
Headspace in VOA Vials >6mm :
OYaa C]Na
2NIA
15.
Trip Blank Present:
Oyes ONO �iv/A
16,
Trip Blank Custody Seals Present
❑Yo9 1JNo
Pace, Trip Blank Lot # (if purchased):
Client Notification/ Resolution: Raid Data Required? Y I N
Person Contacted: Date/Tlme:
Comments! Resolution: _
SCURFISRF
,,
Review:: we, : 9Z258488
� f
Nola: Wheneverco there is a discrepancy eaffecting North Carolina CamplianCe � ��� �� �� ` �■ `� �I
samples, 8 copy of Ihts form tvili be, sent to the, North Carolina DEFINR I 91l IIl it
certification office ( Le out of hold, incorrect preservative, out of temp,
incorrect containers) • 92258488 —
Page 3 of 3
A
14

aceAnalytical
www.pacela6Acara
i
Laboratory Report
Robert Pawelczak
Domino's Pizza Dist of NC
3100 Waterfield Drive
Garner, NC 27529
Project: Retention Pond 7/13115
Pace Project No.: 92258488
Sample: Retention Pond
Lab ID: 92258488001 Collected:
07/13/15 07:40
Parameters
Results Units
Report Limit
Analyzed
Oil and Grease
ND mg1L
5.0
07/22/15 08:42
Total Suspended Solids
7.6 mglL
.2.8
07/15/15 10:01
pH at 25 Degrees C
6.4 Std. Units
1.0
07/15/15 15:14
Chemical Oxygen Demand
38.0 mg/L
25.0
07/16/15 18:30
ANALYTE QUALIFIERS
H6 Analysis initiated outside of the 15 minute EPA recommended holding time.
Reviewed by:
Chris Derouen
[e-mail]
Raleigh Certification IDs
6701 Conference Drive, Raleigh, NC 27607
North Carolina Wastewater Certification * 67
Charlotte Certification IDs
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
South Carolina Certification #: 99006001
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
Massachusetts Certification #: M-NC030
North Carolina Drinking Water Certification #: 37712
Pace Analytical Services, Inc.
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
Report Date: 07/2312015
Date Received: 07113/2015
Matrix: Water
Qualifiers
It;C:
North Carolina Bioassay Certification #: 16
North Carolina Drinking Water Certification #: 37731
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
West Virginia Certification #: 357
VirginialVELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
West Virginia Certification #: 356
VirginialVELAP Certification #: 460222
V
Page 1 of 3

NCDENR arc
Stormwater Discharge Outfall (SDO) CEW
<< ualitative Monitorin - Re ort 'DwR'SECTIp s
,. pit• ai t ' p N
For guidance on filling out this form, please visit: http--/Ipoi-tal.nedeiir.orJweb/wg/ws/sLI//npdcssw#tab-,4
Permit No.: NICI 11 1 1 I I 1 or Certif ate of Coverage No.: NICIGI0I 107 dl 31 S1
Facility Name: dS i Zz Lt-
County:Q „ �'Phorie'No: ���4 —�"7 9 `°�� 2 -,•
Inspector: et L i:i ,, , . , , -:;
Date of Inspection:
Time of Inspection: rxEcaym
AUG 0 7 2015
Total Event Precipitation (inches): CENTRAL FILES
-Yr ,. .
Was this a Representative Storm Event? (See information below) Yes ❑ No DWR SECTION
Please check your permit ta'verify if Qualitative Monitoring must be peifor nM`during a repiesentative
storm event (requirements vary).
A "Representative Storm Event" is a storm -event that measures greater` than Wl inches bf rainfall and that
is preceded by at least 72 hours (3 days) in which no storm event measuring greater than 0.1 inches has
occurred. A single storm event may contain up to 10 consecutive hours of no precipitation.
By this signat , I rtify hat this re accurate and complete to the best of my knowledge:
(Signat -Of_Pe •ttee or Designee)
1. Outfall Description:
Outfall No. l - Structure (p pe, ditch, f
Receiving Stream:�� Cate -
Describe th ind4strial-activities that oc ur within the
,nnc .scat r i IUa e cr.,-�,.
drain a area: t
N i 5yvi l u
r eF if �' °ifi`• xa ,*r. F �;r, y 'y �•Li r E ' 7
2. Color: "Describe the.color of t- je ischarge us'if g b�si�colors (red, brown, blue, eie.) and tint
(light, medium, dark) as descriptors: i5 mot— l i g ��
3. Odor: Describe py distinct odors that the discharge may have (i.e., smells strongly of oil, weak
chlorine odor, etc.): 1A
'i
=Page I=of 2
5WU-242-20120613

4. Clarity: Choose the number which best'describes the clarity of the discharge, where 1 is clear
and 5 is very cloudy:
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stormwater discharge, where I is no solids and 5 is the surface covered with floating solids:
1 3 4 5
6. Suspended Solids: Choose the number.which-best describes the amount of suspended solids in
the stormwater discharge, where 1 is no solids and 5 is extremely muddy: _
I r2 3 4 5
7. ^ Is there any foam in the stormwater discharge? Yes No
8. Is there an oil sheen in the stormwater discharge? Yes No .
9. Is there evidence of erosion -or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may
be indicative of pollutant exposure. , These conditions warrant further investigation.
-Page 2 of 2
SWU-242-20120613

VT.
Stormwaters Dhsch-aiirg'e- Ou''tfall'(SPO)
-Mom orinj,Report
3": 1' lh7zat 'J, 10�w'
For guidance on filling out this form, please visit.- littp:IlporiaLncdenr.org/web/wq/ws/su/npdessw#iab'-4
Pennit No.: NICI I 1 1 1�1. 14 or Certifii c e' of Coverage No.: N/C/G/06/0/13/b/
1 LC
Facility Name:7,>
A cobilty: -k4 S�-
Inspector:
Date of Inspection:
Time of Inspection:
Total Event Pre I cipitation (inches): RECEIVED`
JAN'l 6 2015
Was this a Representative Storm Event? (See information below) F/Y" 0 ""8ENTRAL FILES
DWR SECTION,
Please check your permit to verify if Qualitative Monirortngem4sf- 6e Pe-rf6ihadrin"g a representative
storm event (requirements vary).
A "Representativ"e"Stiorm Ev'enf' is a storih�ev66t' that niel'adsurNe"s' fi.c)'h-;is `6—f­far�'ifall and that
is preceded by at least 72 hours Q days) in which no storm event measuring greater than 0.1 inches has
r
occurred. A single storm event may contain up to 10 consecutive hours of no precipitation,
By this signature, I certify�s po is acc e and 'r—ete to the best of my 4?gledge'.
(Signature Pe 'ittee or Designee)
rrr 1. Utf,,Description: V'6 Outfall No. S tructure- (pipe, ditch. etc.) _"ON D \\J
Receiving Stream:1 L.0 -1� V-, c
Describe the indus 'al . activ'ti s tha occvthiT 41 -K)
6outfall drainage.4reaAAZ-2
tl.
2. Color:
o1b r; 136scf ibe- the c'bl&Sr;8Vth-"6t- "d. i
(light, medium, dark) as descriptors:
3. Odor: Describe any disti
'chlorine odor, etc.):
-iIA60
a -
' eb�ihg balic colors (rid, b6wh,-blue, etc.) and tint
LA 0—
odors that the diieharge may have (i.e., smells strongly of oil, weak
Page I of 2
SWU-242-20120613 4-v I ... '.

4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clew
and 5 is very cloudy:
I .2 ;3 4 5
5. Floating Solids: Choose.the number which. best describes` the, amount of floating solids in the
stormwater discharge, where I is no solids and 5 is the surface covered iwith floating solids:
6. ' Stispended Solids: ' Choose the humberjwhich best describes the amount of suspended solids in
the stormwater discharge, where 1 is no solids and'5 is extremely 'muddy:
1 � 3 4 5
7.. Is there any foam in the stormwater discharge? Yes No N
$: , -Is. there an oil sheen in the stormwater discharge? Yes
9. Is there evidence of erosion or deposition,at the outfall? Yes
10. Other Obvious Indicators of Stormwater'Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may
be indicative of pollutant exposure. These conditionsMwarrantfurther, investigation.
Page 2 of 2
SWU-242-20 [ 206 t3

;aneAnalytical 46
f �- wtrw.paf:alatu.som
r• 6701 Conference Drive, Raleigh, NG 27fi07
Ph: [phone]. lax: (919) 834 Q7
NCWW Cert#67, NCDW COM13MI
Report Results To:
Company: QNA
10C
Attn: Q@W -0%-V RL%a C
Phone: aVO,, 9 r a � N
Fax:
Sampled by (signature):
Chain of Custody
Bdl To:
WA a
ZJCL
Project Reference:
Number:
Project
Purchase Order #:
© Standard Report Delivery
❑Flush Report Delivery (w/surcharge)
"Rush prcf)ecto are subled to f— appavW by
too,
u,rt mborftry
Requested Due Date:
Relinqu ( re)
Received
D
•Z
�o (
TRW
I Ob
nquishea by (signature)
Receitired by (signatrtre
Date
Time
Reunqufshed by {signature)
ReoAred by (signature)
t::t
Reoelpt CondfNOne (t o Only)
Q 4f2°C ❑ Temp. . "C
Res. CN **:
❑ Absent ❑ Present ❑ ft
Add preserv. <27
❑Yes ❑No ❑n/a
Base preserv.>12?
© Yea ❑ No ❑ nla
Page 2 of 3

Ll
130curnent Name, Sample Cc
CBAfldTCaI� ReCal t SCUR
"�•`""' Oocument No.:
1 C tlAf l+c+ nllA -__.
OoWment Revised: April 04,
Pa e 1 of 2
Issuing Authorities:
Pace Ashevilie Quality Off
Ghent Name: `�. .Ia
Where Received: (] Huntersviile Q Ashoviiie - Eden Raleigh
Courfer(Circle): Fed Ex UPS USPS llent� Commercial Paw .Other
Custody Seal on Cooler/Box Present: [] yes Z no Seals Intact: 7� yes [] no
Packing Material: ❑ Bubble Wrap E] Bubble Bags P Nonq_n Other
-Circle Thermometer Used I Gun 3 220853$7Typ of Ice: Vllet Blue -None - d Samples on Ice, cooling pfces!!§ has begun
IR Gun B
Temp Correction Factor: Add
Le�C
Dats and tnitials of person examining
Corrected Cooler Temp.: C
Biological Tissue Is Frozen: Yes WA
Deck; f Alt)
Ternp shoutd be above freezing to 6'C
Comments:
Chaln of Custody Present
vas CINo
❑NIA
4.
Chain of Custody Filled Out:
,PSYee ❑No
❑ WA
2.
Chain otCuSto Relinquished.'
2rY- ❑No
OtwA
3.
Sampler Name & Signature on COC:
QfYea [IN.
❑wA
4.
Samples Arrived within Hold Time;
IfYI,
ONIA
S.
1s
Oct t
Short Hold Time Mai is <72hr :
Yes ON.
IONIA
6.
S
Rush Turn Around Time Requested:
Dyas No
6 WA
7.
SufltclentVolurne:
es ON*
Ot91A
S.
Correct Containers Used:
kw ❑Nn
OwA
9
-Pace Containers Used:
e: ONO
OMA
Containers Intact;
Yes ON.
OWA
10.
Filtered volume -received for Dissolved tests
❑Yes ❑No
&EtLA
11.
Sample Labels match COC:
Yes No
❑NIA
12,
-Includes datefllmeRDlAnal Is Matriac
All containers needing preservation have been checked.
�rYsa ONO
�-`
13WA
13.
All containers needing preservation ere found to be in
As ONo
❑NIA
compliance with EPA recommendation.
axcepUona: VOA. 9oi mr. TOC, O&G, wi-ORO
Water) es ❑t b
Samples checked for deohlorination:
Yes ONO
❑WA
14.
Heads ace In VOA Vials >6mtn :-
❑Yes ❑tiro
QQA
16,
Trip Blank Present:
i]Ye; ONo
1 11A
16.
Trip Blank Custody Seals Present
DYes Me
1 NIA
.
Pace Trie Blank Lot # rchased ,
Client Notification/ Resolution: Field Data R"Ared? Y I N
Person Contecte& DateMme:
Comments/ Resolution: .
SCURF JSR1' did Date: i ' 1 0 �� � ��`
Revlew•• J' 1!z'rl/,ter I ' , - -
Note: Whenever there is a discrepancy affecffng North Cantina aornptiancelf �l
samples, a copy of this form wilt be sent to the North Carolina OEHNR
Certification Office t I.e outorhoid, incorrect preservative, out of temp. : '92228969' ;
incorrect coatalners) _
- - - - .__.,:...Page 3 of 3 I
- a

, ' aceftlylfical
www.pacelab&cnrn
l
Laboratory Report
Robert Pawelczak
Domino's Pizza Dist of NC
3100 Waterfield Drive
Garner, NC 27529
Pace Analytical Services, Inc.
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
Report Date: 12/22/2014
Date Received: 12/10/2014
Project: Retention Pond 1219
Pace Project No.: 92228969
Sample: RETENTION POND Lab ID: 92228969D01 Collected: 12/09/14 17:00 Matrix: Water
Parameters
Results Units
Report Limit
Analyzed Qualifiers
Oil and Grease
ND mg/L
5.0
12/16/14 14:04 -
Total Suspended Solids
ND' mg1L
2.5
12/16/14 12:29
pH at 25 Degrees C
7.5 Sid. Units
1.0 -
,12111114 13:57 H6
Chemical Oxygen Demand
NO mg1L
25.0
12/20/14 11:30
ANALYTE QUALIFIERS
H6 Analysis initiated outside of the 15 minute EPA recommended holding time.
Reviewed by: G/,-- `p L
Chris Derouen
christopher.derouen@pacelabs. com
Raleigh Certification Ids
6701 Conference Drive, Raleigh, NC 27607
North Carolina Wastewater Certification #: 67
Charlotte Certification IDs
9800 Kincey Ave. Ste 100, Hunlersville, NC 28078
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
South Carolina Certification #: 99006001
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
Florida.1NELAP Certification #: E87648
Massachusetts Certification #: M-NC030
North Carolina Drinking Water Certification #: 37712
North Carolina Bioassay Certification #: 16
North Carolina Drinking Water Certification #: 37731
FloridalNELAP Certification #: E87627
Kentucky UST Certification #: 84
West Virginia Certification #: 357
VirginiaNELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
West Virginia Certification #: 356
virginiaNELAP Certification #: 460222
Page 1 of 3

dW1P
;yes
C 6R,Tl f I t A,:
FACILITY,;h
COUNTY'_
SEM 1AN N UALSTORKWATT RID I SCHARG F-MON ITO R1 N&Ri R0 . RT
forr-North Carofin&,Division of1.ate­rQ­uality Gen
eral NC6060000
Labz ert...#
Date submitted
•
LL C
Part A::;Stcirm waidr;Benchm arks Land imonitori n&Res ul ts
'SAMPLEXCICT.ECTION EAR`C)_/
FACILITY ACTIVITIES -INCLUDE (check all thatiapply):
❑ use/process meats E],u'seranimal'f is/byproducts
DISCHARGING TO" SALTWATERS?EJYES Nos.
PLEASE REMEMBER TO SIGN ON THE
Total-eventra.infolj_2 or,E] No -discharge this,perioa3
WC5705711161010
�p I e d5 I I e e
R
mmmomazy W
prH
rStWa6d � "units
Co'
ebp
WrmnjgjIJ1
L
rffi"l
%L 6 f6roffi
.0 lanai per, 04
es per . ml
V —
r!EM6r66djeaJ
bc9c
C N I A per 100ml
Colon
'010
W-efi-Erm-a-MMM
NNSWOMW
SOD or 50,E
11WfthI1")W0nqr6j1
I
W0"36*VWM
Vft§Mfo0A., .�
N11". '5bbAw"
71 7"
77
Only applies to facilities'.that use/process meats.
2 The total precipitation must be recorded using data from anion.site,:ralnigauge. F
For sampling:periods.with no,clischarge.,at.anv outfalls. You m6ft'gtill submit'.th,is(discharge'rri6nitoring report with a checkmark here,
'See Genera ..Permit text, Table 3, identify! n'&the especially s�ensitive..receiving:W6fd'r,El" ssi-ficaiibns where the more protective 'benchmark applies.
.Did thisfacility Maintenance Activitiii' 's'ingtm`6're,'than,55,1'aI ; i.qns,of new motor oil per month? [] yes [:] no
'Part'B:,,Vehilci6Maintenance;Areai.Mo.nitori-ngiResults: only,,,for facilities averaging,> 55'gal,of. new-motor.oll/month.
065ifiI IIN 0.
Sample
--CUr`i—d
ffio/,ddzq�
'd11 ilr qrXdse)M
t 1AITSS1l- il
dL
.; pH;
si;a nda�d unlig
New Motor Oil�Usage,
ma., averiiitial#M..
WeRtWeiffIN
Pallaft"M
M"30W%WW
04WW100rd'rj50M"_
P"W'Or—T9101M
I.
'Only applies tbfaaiitie's�tht:US6/processmeais;.-i k*-.
The,total,'p " inif��i6n-rnust�e!rio'rdbd�6tipg4dqta-,frgri?,a,o,.oqFrsite rain1gauge,
. _f.qc 1 ­­1 ­ I i _ — j IV 1 1, IA14 L.Q.:
3
For,samplln& peric harie',`at Aa[Ijou,tfalls; t-$till sjb'Rt`:t�l?,`d&h-arge-' ig repart.�Vil�'a clie&m7'ar'k here.
,,Y,oufmus , Lrmonitorir
4 Ir, i4, �t i falls,
f, 5 t if receiving
-,_�*M' iW q,
Seei.Gen�e5l;p,er,mit,,te'�t,-.,Ta6le,�3,1�ild6ntifyingithe�opeciallj sensitive receivin"g Wafeli classifications where the-Fhore protective benchmark applies.
SWU-249
complete Part B)
Last Revised: October 18, 2012
Page I of 2

'tO 13, _� I " : *y
k�
.Oe4IA���NCHMMK� EEDANCEPT,,RIGGERS',,TIER�l,,REOUiREMENTS SEE--PERMIT"PA'RT'11!SEC,TI'ON 13�
'­rrtT
• , 2,EXCE C)ANCES-1INi'A.1R5,WiFO EPRAM EAT. E RAT--T,,H A,,,Ee SA RtT H.,EISA M ME.00JTF4LLfklGGERI'Tlik2.REQUIREMENTS. SEE PERMIT PART 11 SECTION B.
'TIER 3 "HAS Y0 U R�FACI NWHAR"4.MR MORE -BENCHMARK EXCEED ENCES FORTH E'SAM E.,PARAM ETE R,AT ANYONE OUTFALL? YES []NO'[:]
ILY S, HAVE., YOU. CONTACTED THE'DAib11_660N0&661f? _YES- 1❑j N6.17.
REGIONAL OFFICE CONTPROME:
6 'z
-�Z�
F-4
ant
Y90
lvlsiRb,�qff Water, Quality
Attn: DWQ Central Files
-161,7:Mail-'Service Center
lika"'He"gh Aq:ti?i;L699`
'7
,,-YOU,'MUST,rSli5NuTHIS.tER,TIFIC-A,TIONIFORrAN.Y.INFORMA,,T,IONzREPOR.T.EO:
11I.0
ertifypundbr-p4nalty<of-'Ibw,it,hit-:.this.do'c.ument-and alli'ittachments-w6re-prepared�under�my.direction-or.'supei� ,,�Jsion,in-accordance;with a
,-system - d esig ned'to-.assu reA haflqbia I ifie d.-, p6rson n e kp rope r[Wgathe r.a nd evaluate-Ahe,inforination -submitted:- Base8,on myinquiryof-the
�-'p,gr�onlorpersonsvhq,mana-.ge!tth-e" "s'tLr;o%lhbse;persohs,dieect y!responsible-for, gatheri�gthe-info'rmatio.n=th6-in,fo;r'mationysub,riiit-ted.fs,p"I'-�''I
to tkibest .W.mylknow e gea6db6li�f,true;-accu�at,,ad,6offioI arp penaItiesfor,subm1tfln%:f6Ise
r 1 n
.p
7-
A 'knowing ,Vio ations.i 16for'mation,-inclu"" -N " ' bilitC ihe�,and,-ir�np t�f8r,,
ding ffb; bssi
k;
}(Signature Mermittee),
(Date),
)V,
A i 'ti 6"n a I '!c o 1pi'e' ofiig orm ffia911564616=16adEd at: http://portal.ncdenr.orb' tab-4
SWU-249 Last Revised: October 18, 2012
Page 2 of 2
4WWA1 1

,opq
JUL 0 9 2014
OdtfAll"(SDO) CENTRAL FILES
Repo
rt ft
Afiffittiv&
For guidance on filling out this form, P�jyqse visit: http brW ncdc:nr.br6/web/walws/su/npdessw#tab4
Permit No.: N/C1 4 orCertific4aeofCoverage No.: MIC/G/06/003/b/
Facility Name: -7�-o-)WVQ ut5 -2 71. 1�
a
'Wtq;�'� x 1,-![: 1,
MOM' ount�,.
c. \77
­z .
Inspector-. ww
Date Of Inspection:
Time of Inspection:
Total Event PtQpitation (inches):
Was this a Representative Storm Event? (See information below) Yes ❑ No
Please check y�d�i-*rm-4 t(:�verify if Qualitati-��eMotn'iio"r-l-n'i��'be'���ji�edvt-rri'r.ng a'representative
storm event (requirements vary).
A "Representative'Siorm Event" is a storrfi 6v&nt tHafmeasur"es-gre'at&1r f idies ofiaisifall and that
is preceded by at least 12 hours (3 days) in which no storm event measuring greater than 0.1 inches has
occurred. A single storm event may contain up to 10 consecutive hours of no precipitation.
By this signature, I. certify that this r�rt is a rat. d co �e to the best of my knowledge:..
00
(Signature. of -Permitte2°Designee) fL,. 7
.I;. OdtfAft Description: 15
�N1 0�J01W,
-OutfaltNo:­ -A - Structure -(pipe, ditch. etc .1WV;;aV
Receiving-Stream: -�SAIA\ C. t
Describe the kndus ial4ctivi6qs th4t,(Tcy�y�ioft6utf a11'&d1ijag- e, 'rea:
orw' d,'15r4ia-bhiF, etc.) an tint 2. Descffethe .color oftfi discharge using basic color re d
'01
(light, medium, 6ri) as descriptors L V X;'
3. Odor: Describe any distinct odors that
chlorine odor, etc.):
may have (i.e., smells strongly of oil, weak
ft.-
5V,rU.242-20120613
I
Pa&Tbf 2

4. Clarity: Choose the number which 15dst;& vibes the clarity of the discharge, where 1 is clear
and 5 is very cloudy:" rr _
r.
1 2 t �3 4 5
xX
5. Floating Solids: Chbose the number which best;descri&ds the amount of floating solids in the
stormwater discharge, where 1 is no solids and 5'is the surface covered-3v[vrth floating solids:
•1,�a.Yt 11; N4' c� ,a . '.ti1d[:•t "Yj
' t •G� .\` _ •-a�_ '. CY'M .. +4s_F�'�V. _ , . -. • r-�yr- t`�[ ,.�,Y.yF..�d'
6. S&p-eA' ded'Solids. 'Choose'thMumberr�which.best describes the amount of"sus'pen&d solids'in
°,.�.: a,'..i�:��4 "',Y"� y J ^^i• .c i ..���-.fa•-'tr' �Y..�.i ._ " ra , ,•
thd'stormwater discharge, where l is no "solidsiand-,5 U extremely muddy: _ _ _ •;
jA
7. Is there any foam in the stormwater discharge?
8. 1s there an oil•sheen in the stone ater discharge?
Yes KON
9. Is, there� evidence of erosion or deposition. at the outfall? .,Yes
P .,,
C)
10. Other 'Ol}vious+Indicators of Stormwater Pallntion:
•{Y h. y. - i 1 .-i,.`�, e�.4}. �T.. C tt • J'.Y s", , � �l 1'.f J) J.
List and_de"c'n e _ _ --
r' •' f " •? f. i3k'ci 7'-' JaJ:. •J3- :).-+=.T 1 'lei..: FTK�' _ - ✓•y
Note: Low clarity, high solids, and/or the presence of foam, oil. sheen, or erosion/depasition may
he indicative of pollutant exposure. These conditions warrant further investigation.
. Siva•, . i"� ,'y',t!' •.�" '��.�.>r';.: r.' ty..�.. �,as^.z
Page 2 of 2
5 W U-242-20120613
r

:S-EM:I"-,ANIN,UAL-'-5T01,R.,MW!A'ititgR�b.iS-.'C-HIR'G EMON 161,61 RIN-6 A-ERim
0 lor-N&; iit'ar'o7ii"na,-'Ijiv'isi'o'n-a- 01-NCG060000
Date submitted
44�
'PLIDCOILItOTION
VM N'... NCG06 A UM
kFACILITW'NAMM--' FAi:[L'IT'Y.ACTlVITIES-INCLUDE,.(�heck all,thaVappl
f Ks COUNTY/Process me - - El use 4ts tL se�animalli /byproducts
L'11 >PERSONJCG-TII! KNGiSA S CilSdH4RGING-TO"tSALTWATERS'�'oyts-- 13fio
N
P
PLEASE. REMEMBER TO SIGN OWTHE REVERSE
,2
Partk-,St6rm 'w-'aie'r*4't�inchmarks;ar�diPAonitor'i�ni,'Resulfs' Totahe ven L rainfa,jor 7:No,discharoe thiS,Deriod?
KQ1-qtLf!Jj[NL'5'M5
M 1110C
H
rStWandl Punilts
C161
am"t M
MER,
haloll i-6.0 31rno .61
31 "11S6,
"rMIJI
IN$
[ifteEnter
p4e
Cq tonl"es
. 0 100 Ml
C-61606s
C 10 M91"
16"'e'nor, -fflM
OrSFTOA
AW7CtlTifiT610."-j9'10'A
Wd*11200M
MOM* ONOM
Njfflmllobfta�"
#Mft0A5p0)MdMft
Sr!l wi
s; �7 r�", V02 �, 1; Z
1T
4N.4
it
'Ohly.ypplies to facilitles:that use/process,,..MeatSL
2
The toiaCpredpita'tlon,must be�-recorclecl�'uslngAata from anj6n-,�'lt-
rl,
this�dlscharge mont oring report with a checkmark here.
3 A , _,., _ ) 'I - it -
For samplingperiocls;wlth no-discharge!,,pt...2nyoutfalls. Your{ EdGit,
4
See General-P&mit text, Table 3, idehti 1 g,the especiMly se'n'si.ti'verqceiving,.wa.ter^6lassi-fications where the more. protectivebenchmark applies.
-Did ,,this,faciliW°perform-VehicleiMilntenanct-:Activiii6s'usin
g gillons ldf-new.motor oil per -month? yes ❑ no
'Part, F! I B-V.6hie!6-,M�ihtenaficdtAr6aiM'on'ltd'rine,Rbsults,..oniv;.forz:i�'C'ilitiL-s:a%;eraeinf!.>'55: al of.new-motor.ollhnonth.
D$tfili NoNew
q Sa leColleted,
ifss,
L
rn g�, 41,L
i.H,
"Units
!WSt nUaFd. units
tan 0 r
w
Motor Oil tg-6-i N
N "e
NO
A uafra%t(
'n ua
�A n I %Milgoa�111, n
LAI [nj OR,
z 9 M M
W-MMMig""M
§*Wf 00 Mor ��Dpt
VM6T0-ff-9T0WM
k 140
1 '0114�,V-
,011
vi,
4
Only. At
The',toFt�4al,�pr- FZcIWiplt"aii6nmust-lIbe,recI4o,rgdeegAhgloa'to'yfk,J!�19.9j. qt*'n'-"s. itet-;4r4-ain�ignaug"p.,
i'' .
''
%
- 4F0rpmp injpercds;�iih4�6-disEhaW,-;QutfjIls�gA ulmussitill-Ubmfth1sN,di h arge-k�o Itaoringepor'w�trh a 6eEkmalrk'here.
SLe,GJeher5ljPehmt-ftie—�,T55fi2 identifylngthKespecially,s6rsitve,receiving-wk r'61assificatons e the protective benchmarkapplies.
i Z
SV-249
(±Yes, complete Part,B)
Last Revised: October 18, 2012
Page 1 of 2

`FO�RJPAR, A AND P.ART:`BtiMO, IITORI�NG RESULTS: ••.:=: y��:: r..,�„ > <'' .:,.' .,,�.� r t : ;•.;.s. � x .
�� �
�cr:• rA 6ENCH11 lA�R, K!EXrC-E,hE}DANCE'TRIGGERSpTIERsti1pREQUIREMEIV S� SE t PERMIT;PAR e 11C1 IrO �B
r. •rfLi.2 EXCEE,DANCEStIN'A`�ROW� OR}�TrHQSAME'PARAMbTEWA,,T'T. E''5AME..OU7FA­EL TRIGGER"'•TIER 2;REQUIREMENTS._SEE:PERMITPART II SECTION B.
• '�TIER�3: ik,A5WY0UR`�FAGIk$I�TY ADt4'OR'NIORE:BJ=NCHMARK EXC£EDENCES FOR THE•SAME',PARAMETER'AT ANY ONE OUTFALL? YES ❑ NO'❑
• ._- �..:� �',`�.�3r :. .. � t•>' •w Sr .N_^Y�.. -1-r- _+✓••!' ... .-. ..... _ _. ,.. -- -
IF.YES HAVE'YOU-CONTACTED TME..DWQ,fiEGIONAf L OFFICE? ` YENO'❑
-REGIONALOFFICE,CONTACTHAME:
r=Y4 {;:-. s6Wou'?..'�1T.i.. y.1`-.'�.�.'Y'1-^N,' -'ei..m','iwNd _'<Y 1 .. r; '., J«�. -v�r
, � �! ,`.i ��4i��a !t v -.i ._ . A'. w i �•�: Yx '�+r'� � A�
'Y$ � le
"Mall an orrdrnahand onPicoplr of th1s DMR includrn a"Yl rscharAer reports�lthrn 3Q days of receln�tmo}�the�la,b `esu_lts or at end o
t} mr o ito 'rrg period in the case 7 !•No Drs'c'rha geg.repo fsl o' '` �
;,;,,c.w sx fit. +i"°,,'-} s'yk `�,;.':'•;^;;io:a V`'t�}� - f a e,'.;.y�_,.sc..: Fl:i�.:�'r+;�` Y',+=sµ
t a'Z
'Y�...., {?�{fit a'L.- f? i{1J ifi}.� K`��j' .: r.7'claFr a. i�M . '�i �:t � f "� ' Y ��Y�+ L. ''"r '.� j iq, 'r,: 'i!{ •gin =•ir", '� ."7��'i'" �`t,�..-
Y .
k. ; #� .Ir :1,:�'T -�;,• •, „ Divisrtna&lNaterQualitYr ��:•x =..
-� e ♦ irf a� - +'.4i'- iN t Y , �..k (> � 4t
Attn. DWQ.Central Files -
• '�� ,. ,fw,����:��� ., '•�..� • , . "�' :�s;�•+ � • ' ...
,�:; „ '' ;, "Ra'Ieigh; NC 2x7�Q9b116�Tr7'�"
> 4.ai{.1..-....ii. ,+y.t• TiSI� k:`'y C(],_"`*',y ' _
,y-.YOUIMUST,SIG1VkTHIS'CER:T,IF.IGA O"N1FO14oANYcINF,ORMAFTIOWEPORTrED:
".I`ceraify;�und�yyerpenalty af,lawat'hatthts docurrient=ani�;all�at'tacfisnent5�were prepared..under3my,direction.or'supervision�in.accordance�fggwith a
,S7CtL�,1 .r k f'.Yr 4, je-' 1 N f,.•, .._.....-..._ . .....y S _ �
,{ sykd n�designedato assure�that qualifiedipeJrsanne� propt?r,ly gather,and.evaftaateathelinformatian_subrrmit�te-ytl,. Basedion.my_inquirykof the
.}...-....-`st4sY d,.} .., °- -".'- i.i r.;wa. wS.: i?ii;.,,,. !% ".-, :re°':rK ...:r,._ _!<�_ .: :�.w fj. •...{A°r't !it.Y� ',i .. '>~ .«.'�
#{i pers�.o�wn or person%s:wh0�manage the system, ,or t'h�Jo''se personsk irectiy.responsible for g�theringAhennfiormation-the"m primationgsuhrnit'tedcis,
$.,;¢,`�. ',.rN-fl"v� #lF;�fi3'J�'..t.'.
f.to'fthe'best of'4my knowledge and b'eli'ef, true; aecuratean: tl'cOrnpletel;;amuawar;Leth�at'rtherare significant penaltiesafors.ub.mlt'ting false
ti;�t .tn.?.y�; .� �' r,S f.,;ni_r."'1; 'S3 't i` `5: .•;� { 1 '" K, M. ; �' a.v tT M^e" ''*; i ,�•� 4".R'. "?!,�, t.r
W' A3e ✓ r . - E N "' S" �r k..,t 'I.r .0
`3nformation'�n4cluding the possibili ' of�sfines�and 1Fn'o sO Me r knowing vialatiansk ,';``'s ��
rt. w�,r h� x•' 1: 1 `v�y,i �'Pk�"�{,•'.: ,t �L'. _ _ ...�.�....,. ,.n...-,.., .n.w..:,,.Rwn�.,.a�..gr .-.t:. -Jl ::. a ICY!'. w.,M' a S :rwLt,•N
;,5 �. i?, _r�4'ti�F.t��T�j s� { -r:. 7;` 3+�;�v �r�!.. 'Fi f' a .:Q i, 6r r. 'k�?!h+f� � ^ .,+?'.. L'....r .i Sr l "� •-.-,�,..,:.
(S nature'"`of�Pe'rmittee] �'x� r y '`` '', (Date)
!. , i''•f�. •� !_.. 1 .=R
t,,,y. r 3 �o-'sr x a:.} 3 rd�Y' r. 5-.• ��.+Lr
'f ' {t:i1. S'-, ,� ..'� S�rltl a�A.� :.f ?� hY". i `if_ g _,ro';i' a � �. u �r� �< rs-
Additional copies Ofit%forni Pha downloadediat:.hdP://nartal,ncdenr.nr /..web/wg(ws/su/.nptlessw#tab=4�
�-
.; ���, ♦ �3 � y�r Y.feK '' R.I{ TN R` 'j /. Tl��. � � S A"{7s ".� r>�M_ ` ill �>�,iy : ��[�- Y T'%'
SWU-249 11 Lust Revised: October 18, 2012'
Page 2 of 2

�s.wr,i ici '" Tritest W.O. #: a•
-- Ghaln of Custody� ��_00�83
6701 Conference Drive, Raleigh, NC 27607
ph: [phone] fax: [phone] DOMINO'S PIZZA DIST:.OF NC
NCWW Cert # 67, NCDW Cert# 37731
Page fof I�
❑ Report Results To: � � Bill Results To: Standard Report Delivery '
DOMINO'S PIZZA DIST. OF NC
3100 WATERFIELD DR.
GARNER,'NC 27529
Attn: Robert Pawelczak
Phone: [phone] Fax: [phone]
DOMINO'S PIZZA,DIST. OF NC
3100 WATERFIELD'DR.
—GARNER, NC 27529
Attn: Sharon Sloop
❑ Rush Report Delivery (wl surcharge)
Requested Due Date:
Project Reference:
Purchase Order #:
Sampled By:
STORMWATER
Note: Ruah projects
are subjmt to prior
approval by Lab
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Total Suspended Solids, Oil & Grease, Feral Coljforms/MF, pH,""Chemical
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Oxygen Demand, pH disclaimer
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ZAnalj4ical
*wwpacelabimm
I
Laboratory Report
Robert Pawelczak
Domino's Pizza Dist of NC
3100 Waterfield Drive
Garner, NC 27529
Project: STORMWATER
Pace Project No.: 92205110
Pace Analytical Services, Inc.
6701 Conference Drive
Raleigh, NC 27607
[phone]
Page 1 of 1
Report Date: 06/27/2014
Date Received: 06/12/2014
Sample: RETENTION POND
Lab ID: 922061100Q1 Collected:
06112/14 11:45 Matrix: Water
Parameters
Results Units
I Report Limit
Analyzed Qualifiers
Oil and Grease
ND mg1L
5.0
06/16/14 09:12
Fecal Coliforms
ND CFU1100 mL
4.0
D6112114 16:04
Total Suspended Solids
5.0 mg1L
5.0
06/14/14 09:47
pH at 25 Degrees C
6.1 Std. Units
1.0
06/13/14 15:35 H6
Chemical Oxygen Demand
95.0 mg1L
25.0
06/21/14 17:50
ANALYTE QUALIFIERS
H6 Analysis initiated outside of the 15 minute EPA recommended holding Gme.
Reviewed by:
Sheila M McGlown
sheila ,[e-mail]
Raleigh Certification IDs
6701 Conference Drive Raleigh, NC 27607
North Carolina Wastewater Certification #: 67
Charlotte Certification IDs
qkb Kincey Ave. St 100, Hunte_rsville, NC 28078
North Carolina Drink ng Water Certification #: 37706
North Carolina Field rvices Certification #: 5342
North Carolina Wastewater Certification #: 12
South Carolina Certification M 99006001
Asheville Certification IDs
2225 Riverside Dr., Asheville, NC 28804
Florida/NELAP Certification #: E87648
Massachusetts Certification #: M-NC030
North Carolina Drinking Water Certification #: 37712
North Carolina Bioassay Certification #: 16
North Carolina Drinking Water Certification #: 37731
Florida/NELAP Certificati n #: E87627
Kentucky UST Certifi(,tH, #: 84
West Virginia Certificatio #: 357
VirginiaNELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
West Virginia Certification #: 356
MrginiaNELAP Certification #: 460222
Page 1 of 4

Document Name: Sarhple Conditlan Upon
Document Revised: April 04, 2013
aCEARaIyiCai"
Recei t SCt1.R
Page 1 of 2
13acumen#No.:
Issuing Autlrities:.
F-RAL.-CS-001-rev.02
Pace Asheville Quality Office
Client Name: —LBO
Where Received: Huntersville [] Asheville Eden �Ralelgti
Cour€er (Circle): " Fed Ex UPS €JSPS CI€ Commercial Pace . Other
Custody Seal on CoolerBox Present: l] yes no Seals Uitact:>eyes no
Packing Material-, Bubble Wrap . ❑ Bubt . )Ie s,6 None Other
Circle Thermometer Used: IR Gun SN;122061, a of ice: W Blue None Samples on Ice, 000ltng process has began
IR Gun Sack Uo 5N:1220653Ti
Temp Correction Factor Add! S ct 167 C
Corrected Cooler Tem .: C Biological Tissue Is Froxen:'Yec N . N!
p ::
Temp should be above twAng.to fi C Comments:
Date'and initials of person examining
GOB f P rvat n •,,
check::
Chaln of Cos dy Present:
Onta
GTN1A
> . - --- -... - ..
.... _....
:r
Chain of Custody Filled Out
Yes .ONo - ONiA
2. '
Chain of Cuttod .. Relinquished:
es ON.
OWA' '
3'.
Sampler Name & Signature on COC:
01. ONo.
ONlA
4. .
Samples Arrived vvithin Hold Time:.
es MW
ONIA
5.'_
Short Hold Time Analysis (<72hr:
Aes ONo
❑NIA
6:
Rush.Turn.Arourid Time Requested:
Oyes o
OAtlA
%.- -
Sufffcient.volume:.
Yes ONo
❑wA
8.
correct Containers Used:
-Pace, Containers Used:
-,HYes ❑No
Yes C]No
OMA
❑FsA
9.
Containers-lntact:
Yes ❑Na
ONlA
10.
Filtered volume -received for Dissolved tests
©Yes ONO
KNIA
11.
Sample Labels match COG:
-Includes dateltlmei€DIAnatysis Matrix
"Yes - ONO
ONrA
12.
PII containers needEng'preservation have been checked.
41 containers needing preservation are found to be in
complianceMith EPA recommendafion.
excaOonx vOA. conform, TOC, O&G, WI-DRO (water)
Yes ❑NO
ptY�, .Ow
/"
Yes ❑No
ONIA
©�A
13.
1
i
Samples checked for dechlorinatlon:
Oyes ONO
ZWA
14.
Headspace In VOA Vials ?6mm):.
Oyes ONO
WA
15.
Trip Blank Present:.
Trip Blank Custody Seals Present
Pace Trip Biank Lot # (if purchased) -.--
OYes Om/NIA
Oyes ❑NsO
16.
Client Not€ficaiion7 Resotut€on: Fleld Data Required? Y I N -
Person Contacted: Date1T€me:
Comments/ Resolution:
SCURF ISRF, Date: �1�31► Place label here.
Review: WO# � 92205 i 10
Note: Whenever there is a discrepancy affecting North Carolina compliance
samples, a copy of this form will be sent to the North Carolina DEHNR
Caft ication Office (Le out of hold, incorrect presarvatrve, out of temp, I Il 11INI
incorrect containers) 92205110 Page 3 of 4

Document Name: 5arnp!9 Condition Upon
Document Revised: April 0-4,= 3
COAna&ft1"
Receipt (SCUR)
Paqi2 of 2
Document No.:
issOng Authorlitlev.
F-RAL-CS-001-rev,02
Pace Asheville Quality Office"
M
is
JA
Jka
as
In
112
as
Is
MEN
IMMMI
Client Sample ID(s)
Sample b1sa6pa'n"cy_
pH Adjustment, Log for Pres.er.ved.S.. Mples
Sample ID
Type of
Preservative
PH upoh
receipt
bate preservation
Adjusted
Time Presemtlon
Adjusted
ArnQunt of
Presewative added
LOW of
Preservative
Bottle Code Key
125, ml Plastic Unp, BP4U
I Liter Amber Unp: AG1 U
.40 ml VOA H2SO4: DG9S
250 ml Plastic Unp: BP3U
1 Liter Amber HCI: AGI H
5035 Kt VOAK
500 ml Plasb&Uhp,. BP2U
500 ml Amber Unp, AG2U
VPH I Gas Kit: VIGK
I Liter Plastic Uhp, 13P1 t3
I Liter Amber H2SO4: AG IS
125 ml Sterile Plastic: SP5T
250 ml Plastic H2SO4: BP3S
260 mi Amber H2804: AG3S
250 ml Sterile Plastic: SP2T
250 ml Plastic HNO3: SP3N
250 ml Amber NH4CL: AG3A
250 ml Plaitic'ZN Acetate; bP3Z
40 ml VOA HCI: DG9H
250 ml Plastic NaOH: BP30-
40 ml VOA Na2$203-, V69T
Wide mouthed glass jar unp: WGFU
.40 ml VOA Unp: vG9U
Page 4 of 4