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Home My WebLink AboutNCG100127_MONITORING INFO_20160419STORMWATER DIVISION CODING SHEET NCG PERMITS PERMIT NO. IV U& f Do j A r7 DOC TYPE ❑ HISTORICAL FILE [,MONITORING REPORTS DOC DATE ❑ a 01 � D4 19 YYYYMMDD Mid Atlantic Engineering & Environmental Solutions April 8, 2016 NCDEQIDWR Attention: Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 RFr,F=I11E® APR 19 201E DWR SECTION INFORMATION PROCESSING UNIT Subject: STORMWATER SAMPLING RESULTS NINE'SAUTO PARTS WAKE FOREST, GRANVILLE COUNTY, NORTH CAROLINA PERMIT NCG1000127� MID -ATLANTIC JOB NO. 00OR2631.00 To Whom It May Concern: 409 Rogers View Court Raleigh, NC 27610 office 919.250.991a facsimile 919.250.9950 MAAONLINE.COM Attached please find the Stormwater Discharge Monitoring Report (DMR) and analytical report for the sampling conducted at the above -referenced site. A sormwater sample was collected on March 17, 2016 and analyzed for total suspended solids (TSS), pH, total recoverable lead, oil and grease and ethylene glycol. As indicated on the attached DMR, all parameters were below their respective benchmark values or within their benchmark range. If you have any questions or need additional information, please contact me at 919-250-9918 Sincerely, MID -ATLANTIC ASSOCIATES, INC. Ron Davis Stormwater Services Manager Attachments: Stormwater Discharge Monitoring Report Laboratory Analytical Report EXPERIENCED CUSTOMER FOCUSED INNOVATIVE STORMWATER DISCHARGE OUTFALL (SDO) MONITORING REPORT CERTIFICATE OF COVERAGE NO. NCG1000127 FACILITY NAME Nine's Auto Parts PERSON COLLECTING SAMPLE(S)Jamie Gilkes CERTIFIED LABORATORY(S) Pace Analytical _Lab #12 Lab # Part A: Stormwater Benchmarks and Monitoring Results SAMPLES COLLECTED DURING CALENDAR YEAR:2016 (This monitoring report shall be received by the Division no later than 30 days from the date the facility receives the sampling results from the laboratory.) COUNTY Granville PHONE NO. 919 832-9549 PLEASE REMEMBER TO SIGN ON THE REVERSE 4 For sampling periods with no discharge, you must submit this discharge monitoring form noting "No Flow" or "No Discharge" within 30 days of the end of that period to comply with permit reporting requirements. Outfall No. Date Sample Collected, mo/dd/year Total Rainfall, inches 00400 00530 - - - - 77023 01051 78141 pH, Standard Units Total Suspended Solids (TSS), mg/L Non -polar O&G/TPH (Method 1664 SGT-HEM), mg/L Ethylene Glycol, mg/L Lead, Total Recoverable, mg/L Total Toxic 3 Organics , mg/L Benchmark - - 6.0 — 9.01 100/502 15 8,000 (Tiers 2 and 3) 0.03 1.0 Outfall001 03/17/16 2.0 <3.0 <5.0 <5.0 <0.0050 NA Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier 1 or Tier 2 responses in the General Permit. 1See If pH values outside this range are recorded in sampled stormwater discharges, but ambient precipitation pH levels are lower, then the lower threshold of this benchmark range is the pH of the precipitation (within instrument accuracy) instead of 6 S.U. Readings from an on -site or local rain gauge (or lal precipitation data) must be documented to demonstrate background concentrations were below the benchmark pH range of 6-9. 2See General Permit text to identify whether the more protective benchmark applies for especially sensitive receiving waters. Form SWU-251, last revised October 25, 2012 Page 1 of 2 STORMWATER DISCHARGE OUTFALL (SDO) MONITORING REPORT 3For purposes of this permit the definition of Total Toxic Organics is that list as stated in Appendix D, Table If of Chapter 40 Code of Federal Regulations (CFR) Part 122. Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan may request that DWQ waive monitoring of total toxic organics. The solvent management plan shall include a list of the total toxic organic compounds used and the other elements listed in the General Permit. For those facilities allowed such a waiver, the discharger shall sign the following certification statement: Solvent Management Plan Certification Statement "Based upon my inquiry of the person or persons directly responsible for managing compliance with the permit monitoring requirement for total toxic organics (TTO), I certify that to the best of my knowledge and belief, no dumping of concentrated toxic organics into the stormwater or areas which are exposed to rainfall or stormwater runoff has occurred since filing the last discharge monitoring report. I further certify that this facility is implementing all the provisions of the solvent management plan included in the Stormwater Pollution Prevention Plan." Name (Print name) Title (Print title) Signature Mail Original and one copy to: Division of Water Quality Attn: Central Files 1617 MailServiceCenter Raleigh, North Carolina27699-1617 Date "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations." of Permittee or Designee) IC/ -� (Date) Form SW U-251, last revised October 25, 2012 Page 2 of 2 m aceAnalytical www.paceJabs.com March 24, 2016 Chuck Hoffman Mid -Atlantic Associates, Inc 409 Rogers View Court Raleigh, NC 27610 RE: Project: NINE'S AUTO SALVAGE Pace Project No.: 92290755 Dear Chuck Hoffman: Pace Analytical Services, Inc. 9800 KinceyAve. Suite 100 Huntersville, NC 28078 (704)875-9092 Enclosed are the analytical results for sample(s) received by the laboratory on March 19, 2016. The results relate only to the samples included in this report. Results reported herein conform to the most current TNI standards and the laboratory's Quality Assurance Manual, where applicable, unless otherwise noted in the body of the report. Analyses were performed at the Pace Analytical Services location indicated on the sample analyte page for analysis unless otherwise footnoted. If you have any questions concerning this report, please feel free to contact me. Sincerely, Nicole Gasiorowski nicole.gasiorowski@pacelabs.com Project Manager Enclosures cc: Ron Davis, Mid Atlantic Associatees, Inc. e pCCREO `AeORA�� REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, without the written consent of Pace Analytical Services, Inc.. Page 1 of 12 aceAnalytical" www.pacelabs.c m Pace Analytical Services, Inc. 9800 KinceyAve. Suite 100 Huntersville, NC 28078 (704)875-9092 Project: NINE'SAUTO SALVAGE Pace Project No.: 92290755 Indiana Certification IDs 7726 Moller Road, Indianapolis, IN 46268 Illinois Certification #: 200074 Indiana Certification #: C-49-06 KansaslNELAP Certification #:E-10177 Kentucky UST Certification #: 0042 Kentucky WW Certification #:98019 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 #: 12 Asheville Certification IDs 2225 Riverside Drive, Asheville, NC 28804 Florida/NELAP Certification #: E87648 Massachusetts Certification #: M-NCO30 North Carolina Drinking Water Certification #: 37712 CERTIFICATIONS Ohio VAP Certification #: CL-0065 Oklahoma Certification #: 2014-148 Texas Certification #• T104704355-15-9 West Virginia Certification #: 330 Wisconsin Certification #: 999788130 USDA Soil Permit #: P330-10-00128 South Carolina Certification #: 99006001 Florida/NELAP Certification #: E87627 Kentucky UST Certification #: 84 VirginiafVELAP Certification #: 460221 North Carolina Wastewater Certification #: 40 South Carolina Certification #: 99030001 Virginia/VELAP Certification #: 460222 REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, without the written consent of Pace Analytical Services, Inc.. Page 2 of 12 aceAnalytical www. pacelabs.com Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 SAMPLE ANALYTE COUNT Project: NINE'S AUTO SALVAGE Pace Project No.: 92290755 Analytes Lab ID Sample ID Method Analysts Reported Laboratory 92290755001 OUTFALL NO. 1 EPA 16646 JMS 1 PASI-C EPA 8015 Alcohol -Glycol BJW 1 RASH EPA 6010 CDF 1 PASI-A SM 2540D MJP 1 PASI-A REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, without the written consent of Pace Analytical Services, Inc.. Page 3 of 12 (.17'aceAnalyficale wwwpacelabs.com ANALYTICAL RESULTS Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 Project: NINE'S AUTO SALVAGE Pace Project No.: 92290755 Sample: OUTFALL NO. 1 Lab ID: 92290755001 Collected: 03/17/16 16:30 Received: 03/19/16 09:25 Matrix: Water Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual 1664 SGT-HEM, TPH Analytical Method: EPA 1664B Total Petroleum Hydrocarbons ND mg/L 5.0 1 03/22/16 09:21 8015M Glycols in water Analytical Method: EPA 8015 Alcohol -Glycol Ethylene glycol ND mg/L 5.0 1 03/23/16 10:41 107-21-1 6010 MET ICP Analytical Method: EPA 6010 Preparation Method: EPA 3010A Lead ND ug1L 5.0 1 03/22/16 20:00 03/23/16 15:57 7439-92-1 2540D Total Suspended Solids Analytical Method: SM 2540D Total Suspended Solids ND mg/L 3.0 1 03/22/16 11:20 REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 03/24/2016 02:50 PM without the written consent of Pace Analytical Services, Inc.. Page 4 of 12 aceAnalytical tyww.paaelabs.snm Project: NINE'SAUTO SALVAGE Pace Project No.: 92290755 QC Batch: GCSV124463 QC Batch Method: EPA 16648 Associated Lab Samples: 92290755001 METHOD BLANK: 1691611 Associated Lab Samples: 92290755001 Parameter Units Total Petroleum Hydrocarbons mglL LABORATORY CONTROL SAMPLE: 1691612 Parameter Units Total Petroleum Hydrocarbons mglL Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 QUALITY CONTROL DATA Analysis Method: EPA 1664B Analysis Description: 1664 SGT-HEM, TPH Matrix: Water Blank Reporting Result Limit Analyzed Qualifiers ND 5.0 03/22/16 09:13 Spike LCS LCS % Rec Conc. Result % Rec Limits Qualifiers 20 14.5 72 64-132 MATRIX SPIKE SAMPLE: 1691613 92289674001 Spike MS MS % Rec Parameter Units Result Conc. Result % Rec Limits Qualifiers Total Petroleum Hydrocarbons mg/L ND 20 19.1 96 64-132 Results presented on this page are in the units Indicated by the "Units" column except where an alternate unit is presented to the right of the result. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 03/24/2016 02:50 PM without the written consent of Pace Analytical Services, Inc.. Page 5 of 12 ace Analytical www.pacelabs.com Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 Project: NINE'S AUTO SALVAGE Pace Project No.'. 92290755 QC Batch: GCSV/18952 QC Batch Method: EPA 8015 Alcohol -Glycol Associated Lab Samples: 92290755001 METHOD BLANK: 1503306 Associated Lab Samples: Parameter Units Ethylene glycol mg/L QUALITY CONTROL DATA Analysis Method: EPA 8015AIcohol-Glycol Analysis Description: EPA 8015 Modified Matrix: Water Blank Reporting Result Limit Analyzed Qualifiers ND 5.0 03/23/1610:22 LABORATORY CONTROL SAMPLE: 1503307 Spike LCS LCS e/a Rec Parameter Units Conc. Result % Rec Limits Qualifiers Ethylene glycol mg/L 25 21.3 85 60-129 MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 1503308 1503309 MS MSD 92290755001 Spike Spike MS MSD MS MSD % Rec Parameter Units Result Conc. Conc. Result Result % Rec % Rec Limits RPD Qual Ethylene glycol mg/L ND 25 25 23.9 21.6 96 87 23-157 10 Results presented on this page are in the units Indicated by the" Units" column except where an alternate unit is presented to the right of the result REPORT OF LABORATORY ANALYSIS This report shall not he reproduced, except in full, Date: 03/24/2016 02:50 PM without the written consent of Pace Analytical Services, Inc.. Page 6 of 12 acEAnalytical www.pacefabs.wrn Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersvilte, NC 28078 (704)875-9092 QUALITY CONTROL DATA Project: NINE'S AUTO SALVAGE Pace Project No.: 92290755 QC Batch: MPRP121060 Analysis Method: EPA 6010 QC Batch Method: EPA 3010A Analysis Description: 6010 MET Associated Lab Samples: 92290755001 METHOD BLANK: 1692341 Matrix: Water Associated Lab Samples: 92290755001 Blank Reporting Parameter Units Result Limit Analyzed Qualifiers Lead ug/L ND 5.0 03/23/16 15A 0 LABORATORY CONTROL SAMPLE. 1692342 Spike LCS LCS % Rec Parameter Units Conc. Result % Rec Limits Qualifiers Lead ug1L 500 450 90 80-120 MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 1692343 1692344 MS MSD 92290775001 Spike Spike MS MSD MS MSD % Rec Parameter Units Result Conc. Conc. Result Result % Rec % Rec Limits RPD oval Lead ug/L ND 500 500 500 434 99 86 75-125 14 H3 Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented to the right of the result. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 03/24/2016 02:50 PM without the written consent of Pace Analytical Services, Inc.. Page 7 of 12 aceAnalj&al www.pacelabs.com Pace Analytical Services, Inc. 9800 KinceyAve. Suite 100 Huntersville, NC 28078 (704)875-9092 QUALITY CONTROL DATA Project: NINE'S AUTO SALVAGE Pace Project No.: 92290755 QC Batch: WET143720 Analysis Method: SM 2540D QC Batch Method. SM 2540D Analysis Description: 2540D Total Suspended Solids Associated Lab Samples: 92290755001 METHOD BLANK: 1691659 Associated Lab Samples: 92290755001 Parameter Units Total Suspended Solids mg/L LABORATORY CONTROL SAMPLE: 1691660 Parameter Units Total Suspended Solids mglL SAMPLE DUPLICATE: 1691661 Parameter Total Suspended Solids SAMPLE DUPLICATE: 1691662 Parameter Total Suspended Solids Matrix: Water Blank Reporting Result Limit Analyzed Qualifiers ND 2.5 03/2211611.18 Spike LCS LCS % Rec Conc. Result % Rec Limits Qualifiers 250 236 94 90-110 92290631006 Dup Units Result Result RPD Qualifiers mglL ND ND 92290724003 Dup Units Result Result RPD Qualifiers mg1L ND ND Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented to the right of the result. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 03/24/2016 02:50 PM without the written consent of Pace Analytical Services, Inc.. Page 8 of 12 aceAnalytical w+vw.pacelabs.com QUALIFIERS Project: NINE'S AUTO SALVAGE Pace Project No.: 92290755 DEFINITIONS DF - Dilution Factor, if reported, represents the factor applied to the reported data due to dilution of the sample aliquot. ND - Not Detected at or above adjusted reporting limit. J - Estimated concentration above the adjusted method detection limit and below the adjusted reporting limit. MDL -Adjusted Method Detection Limit. PQL - Practical Quantitation Limit. RL - Reporting Limit. Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 S - Surrogate 1,2-Diphenylhydrazine decomposes to and cannot be separated from Azobenzene using Method 8270. The result for each analyte is a combined concentration. Consistent with EPA guidelines, unrounded data are displayed and have been used to calculate % recovery and RPD values. LCS(D) - Laboratory Control Sample (Duplicate) MS(D) - Matrix Spike (Duplicate) DUP - Sample Duplicate RPD - Relative Percent Difference NC - Not Calculable. SG - Silica Gel - Clean -Up U - Indicates the compound was analyzed for, but not detected. Acid preservation may not be appropriate for 2 Chloroethylvinyl ether, Styrene, and Vinyl chloride. A separate vial preserved to a pH of 4-5 is recommended in SW846 Chapter 4 for the analysis of Acrolein and Acrylonitrite by EPA Method 8260. N-Nitrosodiphenylamine decomposes and cannot be separated from Diphenylamine using Method 8270. The result reported for each analyte is a combined concentration. Pace Analytical is TNI accredited. Contact your Pace PM for the current list of accredited analytes. TNI -The NELAC Institute. LABORATORIES PASI-A Pace Analytical Services -Asheville PASI-C Pace Analytical Services - Charlotte PAST -I Pace Analytical Services - Indianapolis ANALYTE QUALIFIERS H3 Sample was received or analysis requested beyond the recognized method holding time. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 03/24/2016 02:50 PM without the written consent of Pace Analytical Services, Inc.. Page 9 of 12 aceAnalytical mvw.pacelabs.=n Pace Analytical Services, Inc. 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 QUALITY CONTROL DATA CROSS REFERENCE TABLE Project: NINE'S AUTO SALVAGE Pace Project No.: 92290755 Analytical Lab ID Sample ID QC Batch Method QC Batch Analytical Method Batch 92290755001 OUTFALL NO. 1 EPA 1664E GCSV124463 92290755001 OUTFALL NO. 1 EPA 8015AIcohol-Glycol GCSV/18952 92290755001 OUTFALL NO. 1 EPA 3010A MPRP121060 EPA 6010 ICP118946 92290755001 OUTFALL NO. 1 SM 2540D WET143720 Date: 03/24/2016 02:50 PM REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, without the written consent of Pace Analytical Services, Inc,. Page 10 of 12 Document Name: Document Revised: 18FE82Ulb 4 Sample Condition Upon Receipt(SCUR) Page 1 of 2 aceAnalj4tal Document No.: Issuing Authority: F-CHR-CS-003-rev.18 Pace Huntersvllle Quality Office Client Name: Project �. �O : 922g0755 • • y � F 1 Courier: Fed Ex ❑UPS ❑USPS []Client ❑ Commercial []Pace ❑Other: 92290738 _ I Custody Seal Present? ❑Yes ❑No Seals Intact?.— ❑Yes []No pate/Initials Person Examining Contents: ✓� r Packing Material: ❑Bu 12 Wrap ❑Bubble Bags ❑None,�-❑Other. Thermometer: 0 11505 ❑ Type of Ice: ❑wec ❑Blue ❑None ❑Samp1� e, cooling process has be n Correction Factor: 0.0'C Cooler Temp Corrected ('C): Biological Tissue Frozen? []Yes[]NO' N/A Temp should be above freezing to VC USDA Regulated Soil. (❑ N/A, water sample) Did samples originate in a quarantine zone within the United States: CA, NY, or SC (check maps)? Did samples originate from a foreign source (internationally, Dyes ❑No including Hawaii and Puerto Rico)? ❑Yes [)IVo COMMENTS: Chain of Custody Present? Yes No ❑N/A 1. Chain of Custody Filled Out? Yes BNO ❑N/A 2. Chain of Custody Reiln u[shed? es ❑No ❑N/A 3. Sampler Name and/or Signature on COC? es ON. ❑N/A 4. Samples Arrived within Hold Time? Yes EINO N/A S. Short Hold Time Analysts (<72 hr.)? ❑Yes ❑ o ❑N/A 6. Rush Turn Around Time Requested? Yes bN1 ❑N/A 7. Stiff icient Volume? ❑ es ❑No [I N/A 8. Correct Containers Used? Yes []NO [I N/A 9. -Pace Containers Used? Ye ❑No ❑N/A Containers Intact? CJYes ❑No- ❑N/A Filtered Volume Received for Dissolved Tests? []Yes No ONIA 11. Note if sediment is visible in the dissolved container Sample Labels Match COV Yes []NO ❑N/A 12. -Includes Date/Time/ID/Anal sis Matrix: W All containers needing acid/base preservation have been 13 checked? Yes ❑No ❑NIA All. containers needing preservation are found to be in compliance with EPA recommendation? (HNO;, H2504, HCI<2; NaOH >9 Sulfide, NaOH>12 Cyanide) No [I N/A Exceptions: VOA, Coliform, TOC, Oil and Grease, �Y�esEQ]No ORO/8015 (water) DOC,LLHg ❑N/A Samples checked for dechlorination ❑Yes ❑No ❑ /A 14. Headspace in VOA Vials (>5-6mm)? []Yes ONO ❑ /A 15. Trip Blank Present? ❑Yes []No ❑ /A 16. T rip Blank Custody Seals Present? Des []NO ❑N/A Pace Trip Blank Lot H (if purchased): CLIENT NOTIFICATION/RESOLUTION Person Contacted: Comments/Resolution: Date/Time: Field Data Required? []Yes []NO Project Manager SCURF Review: IAN Date: Project Manager SRF Review: q�kti Date: Note: Whenever there is a discrepancy affectin North Carolina compliance samples, a copy of this form will be sent to the North Carolina DEHNR Certification Office (i.e. .Out of hold, incorrect preservative, out of temp, Incorrect containers) Page 11 of 12 CHAIN -OF -CUSTODY 1 Analytical Request Document �alceAnalyfical The Chain -of -Custody is a LEGAL DOCUMENT, All relevant fields must be completed accurately. j ,. �. ...;-•.nn. car r Section A Section R Section C Required orient Information: Required Proiect Information: Invoice Information: Company: Mid -Atlantic Associates, Inc. Report To: Chuck Hoffman (choffman@maaonline.com) Atlention: Chuck Hoffman CN 0 Page: n! m Addres& 409 Rogers View Court copy To: Ron Davis (rdavis@ntaaonline.com Company Na— Mid -Atlantic Associates, inc. REGULATORY AGENCY Raleigh. NC 27610 Address: 409 Rogers View Court, Raleigh, NC j"- NPDES i— GROUND WATER i— DRINKING WATER f UST F RCRA t— OTHER Email To: choffman@maaonline.com Purertase Order No.: R2631.00 Pace Quote — Reference: W H V1141-45u-aylil rax: 919-250-VU50 PTOIeLt Name: Nines Auto Salvage �d Due Date/TAT! Standard lPmjeci Number. R2531.00 Alon D Valid Matrix Codes e �uIred Gies, Information MATRI CooE e o COLLECTED DRIW( WATER DW U WATER WT g P U WASTE WATER WW COMPMTE cosIpows PRODUCT SOLMOM P SL 'e START ENDMIRA9 OIL 01. SAMPLE IDE !A-Z.0-91.-) AIR OTHER AR aT W Lu Sample IDS MUST BE UNQUE TISSUE Ts p IL U X j aa DATE TIME DATE Outfall No. 1 Wr G i - _ _ X-7/1!- L, vrgeu Nicole Gasicrowski Site Location ger. NC Pmr,e t: STATE: I Requested Analysis Filtered (YIN) Preservatives l> 1 N I Y l N l Y Z O ? v R W 0 w o ZO U N N Y p N d) d) O 2 TIME r� a 2= x Z Z M O tit Co d m 0 V w 11 Pace Project NoJ Lab „- I 12 ADDITIONAL COE MMNTS RELINQUISHED BY I, AFFILIATION - t' DATE . • ..TIME - �ACCEPP.T�EEp BY I AFF61ATION ' DATE - � TIME - SAMPLE CONDITIONS SAMPLER NAME AND SIGNATURE PRINT Name or SAMPLER: �"�. r,�.1 r •� SIGNATURE of SAMPLER:y�r4 -important Note: BY signing this Tomn you are accepl4q Pace's NET 30 dry paymar, terms and agreeing to Wta charges of 1.5%per month foe any smokes no pW within 30 days U m m o — Z Signed E F-ALL-Q-020 rev.0 8. 12-Oct-2007