HomeMy WebLinkAbout6004_DukeMcGuire_LF1_LFGWorkPlan_FID1741298_20221005PREPARED FOR:
Duke Energy Carolinas, LLC
526 South Church Street
Charlotte, North Carolina 29111
PREPAF
S&ME, Inc.
3201 Spring Forest Road
Raleigh, NC 27616
Corporate Registration for Licensing of NC Geologists No. C-145
NC Engineering Firm No. F-0176
October 5, 2022
=0
October 5, 2022
North Carolina Department of Environmental Quality
Division of Waste Management - Solid Waste Section
217 West Jones Street
Raleigh, North Carolina 27605
Attention: Ms. Sarah Moutos via email: sarah.moutos@ncdenr.gov
Environmental Program Consultant
Reference: Work Plan for Landfill Gas Sampling (Permit No. 6004-INDUS-1981)
Duke Energy - McGuire Nuclear Station - Landfill No. 1
13339 Hagers Ferry Road, Huntersville, North Carolina
S&ME Project No. 22350048
Dear Ms. Moutos:
S&ME, Inc. (S&ME) on behalf of our client, Duke Energy of the Carolinas, LLC (Duke Energy), is submitting this
Work Plan to conduct landfill gas sampling activities at the above -referenced site. Duke Energy is voluntarily
capping Landfill # 1 at the McGuire Nuclear Station, with a 40-mil LLDPE geomembrane cover. This Work Plan is
intended to collect landfill gas measurements and laboratory data to support facility closure and post -closure
design, by evaluating whether landfill gas vents would be necessary in the final cover system design and whether
landfill gas monitoring would be necessary during the post -closure period, with the updated final cover system.
If you have any questions, or comments, about the enclosed Work Plan please contact the
Sincerely,
S&ME, Inc.
Laura Beth Slagle
Environmental Staff Professional
Islagle@smeinc.com
Samuel P. Watts, PG
Principal Geologist/Senior Environ
swatts@smeinc.com
NC Licensed Geologist No. 1806
cc: Ashley Healy, Duke Energy (ashley.healy@duke-energy.com)
Jamie Lineberger, Earnhardt Grading (iamie@earnhardt- rq adinQ.com)
Sharon Korleski, S&ME, Inc. (skorleski@smeinc.com)
Elizabeth Werner, DWM-SWS (elizabeth.werner@ncdenr.Qov)
Claire Osborn, DWM-SWS (claire.osborn@ncdenr.aov)
Sherri Stanley, DWM-SWS (Sherri.Stanley@ncdenr.gov)
Jordan Russ, DWM-SWS (iordan.russ@ncdenr.00v)
Ed Mussler, DWM-SWS (ed.mussler@ncdenr.dov)
iderr i ned.
CA
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EEL-1806
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fivi Consultant
S&ME, Inc. 13201 Spring Forest Road I Raleigh, NC 27616 1 p 919.872.2660 1 www.smeinc.com
s Work Plan for Landfill Gas Sampling
r Duke Energy — McGuire Nuclear Station
I Landfill No. 1 (Permit No. 6004-INDUS-1981)
S&ME Project No. 22350048
Table of Contents
1.0 Introduction and Project Background...........................................................................2
2.0 Project Preparation — Health & Safety..........................................................................3
3.0 Gas Implants Installation and Sampling Procedures................................................3
3.1 Gas Implant Installation................................................................................................................ 3
3.2 Field Screening................................................................................................................................3
3.3 Sampling Collection....................................................................................................................... 4
3.4 Laboratory Analysis: ...................................................................................................................... 4
4.0 Quality Assurance/Quality Control..............................................................................5
4.1 Sampling Equipment.....................................................................................................................5
4.2 Sample Custody..............................................................................................................................5
4.3 Laboratory Analytical Report.......................................................................................................5
5.0 Reporting............................................................................................................................5
6.0 References...........................................................................................................................6
List of Figures
Figure 1 — Site Map with Proposed Sampling Locations
Figure 2 — LFG Sample Train Schematic
List of Attachments
Attachment I — Implants Operation from Geoprobe Systems Sampling Field Forms
Attachment 11 — Sampling Field Forms
Attachment III — Blank Chain of Custody
October 5, 2022 1
s Work Plan for Landfill Gas Sampling
r Duke Energy — McGuire Nuclear Station
Landfill No. 1 (Permit No. 6004-INDUS-1981)
S&ME Project No. 22350048
1.0 Introduction and Project Background
S&ME, Inc. (S&ME) on behalf of our client, Duke Energy of the Carolinas, LLC (Duke Energy), is submitting this
Work Plan to conduct landfill gas (LFG) sampling activities at the above -referenced site. Duke Energy is voluntarily
capping Landfill # 1 at the McGuire Nuclear Station, with a 40-mil LLDPE geomembrane cover. This Work Plan is
intended to collect landfill gas measurements and laboratory data to support facility closure and post -closure
design, by determining whether landfill gas vents would be necessary in the final cover system design and
whether landfill gas monitoring would be necessary during the post -closure care period, with the updated final
cover system.
The referenced property is located at 13339 Hagers Ferry Road, Huntersville, Mecklenburg County, North Carolina,
and is owned by Duke Energy. Landfill #1 has a footprint area of approximately 12 acres. A site map depicting
the aerial extent of the landfill, with proposed sampling locations, is provided as Figure 1. The application for the
landfill was originally submitted in 1972 to accept construction material and other wastes including paper, cans,
lunch box scrap and fish waste. Additional disposal of oil absorbent materials, carbon granules, sludge, borax,
diatomaceous earth, and ion exchange resins were permitted under a case -by -case basis. This landfill was
permitted in 1981 (Permit No. 60-04). Closure of the Landfill was completed in 1993 with construction of an
earthen cover consisting of approximately two feet of compacted soil.
Volatile organic compounds (VOCs) exceeding state regulatory standards have been reported, at the landfill
review boundary, during the semi-annual groundwater monitoring events. Subsequently, Duke Energy voluntarily
conducted site characterization to improve the conceptual site model of the landfill. A Site Characterization
Report, dated May 21, 2021, prepared by Wood summarized results of field activities conducted for the Site
Characterization, which included surficial geophysics and passive soil gas sampling within the Landfill limits;
borehole drilling to facilitate five bedrock and one basal saprolite/transition zone well installations; downhole
geophysics and packer testing in the bedrock boreholes; monitoring well development and sampling; and land
surveying of the new wells. A total of 25 Passive Soil Gas (PSG) Samplers were deployed in a graded grid pattern
biased in the northwestern half of the waste area.
Duke Energy concluded an upgraded closure cap on Landfill # 1 could serve as a proactive measure to
significantly reduce infiltration from precipitation through the landfill waste mass, thus limiting constituent of
concern migration to groundwater. Duke Energy is currently preparing a design for the upgraded closure cap,
and as part of closure considerations, has requested S&ME to conduct landfill gas sampling. The intent is to
collect landfill gas measurements and laboratory data to possible support closing the landfill without requiring
LFG vents or LFG monitoring, if sample results are reported at lower than action levels. This LFG assessment work
plan is intended to be provided to the Duke Energy and the Division of Waste Management, Solid Waste Section
(Section) for approval.
October 5, 2022
=0
2.0 Project Preparation - Health & Safety
S&ME will conduct the following:
Work Plan for Landfill Gas Sampling
Duke Energy — McGuire Nuclear Station
Landfill No. 1 (Permit No. 6004-INDUS-1981)
S&ME Project No. 22350048
Communicate with Duke Energy and site personnel to confirm access and schedule.
Acquire approval from the Section, and Duke Energy, to drill at the proposed sample locations depicted
on Figure 1. S&ME will not be responsible for damage to utilities that are not clearly marked on the
ground surface.
Prepare a site -specific health and safety plan to comply with 29 CFR 1910.120 as required by the
Occupational Safety and Health Administration (OSHA).
3.0 Gas Implants Installation and Sampling Procedures
Landfill #1 has a footprint area of approximately 12 acres. S&ME proposes to install up to 24 gas implants at the
approximate locations shown on the attached figure. The following activities and tasks will be completed for the
landfill gas implant installations, screening and sampling.
3.1 Gas Implant Installation
Using direct push techniques via a track -mounted Geoprobes rig, S&ME will install up to 24 gas implants for the
collection of LFG samples across the waste disposal unit. S&ME will install the implants to a depth of 10 feet
below ground surface (ft-bgs), as depicted on Figure 2 and in general conformance with Geoprobe's "Implants
Operation" manual (Attachment 1).
3.2 Field Screening
Following installation of the implants, S&ME will field screen the newly installed implants for the presence of
landfill gases. Portable meters will be used to collect the following parameters at each gas implant location.
Landfill Gas Meter — GEM 5000 Plus for:
methane: 0-100%
hydrogen sulfide: 0-500 ppmv
carbon dioxide: 0-100%
oxygen: 0-25%
barometric pressure
A thermo-hygrometer will be used to measure ambient air for humidity, and temperature.
The GEM 5000 Plus has an internal pump. New Teflon tubing will be connected from the meter to each implant
for screening. Instruments will be calibrated in the field following manufacturer recommendations for each
instrument. A summary of field calibration procedures used (according to manufacturer's recommendations) and
bump tests (to verify full calibration and instrument accuracy) performed before, during, and after evaluation will
be documented. Additional field calibrations that may be required for changing field conditions (such as
barometric pressure or temperature) will be documented. Three background readings will be collected away from
the waste disposal area.
October 5, 2022
Work Plan for Landfill Gas Sampling
Duke Energy — McGuire Nuclear Station
Z
Landfill No. 1 (Permit No. 6004-INDUS-1981)
S&ME Project No. 22350048
Field logs will be maintained and will include at a minimum:
Names of persons conducting the evaluation.
Brief description of weather conditions
Date and time began/ended.
Ambient temperature, humidity, and barometric pressure readings at least hourly.
Verification of field instrument calibration.
Additional field calibration as needed for changing field conditions.
Duplicate readings from at least one background and two probes.
Detection limit of each instrument used.
A table that includes sample location, readings, and notations of other things that may affect the results
(e.g., water trap, filters, barometric pressure, temperature, etc.).
3.3 Sampling Collection
LFG samples will be collected for laboratory analyses based on the following:
If field screening does not detect LFG constituents, three samples (approx. 10%), from three separate
locations, will be collected for laboratory analysis. The samples will be collected from the central portion
of the landfill, away from the edges of the landfill.
If field screening does detect LFG constituents, five samples (approx. 20%), from five separate locations,
will be collected for laboratory analysis. The samples will be collected from the locations with the highest
detections recorded from field screening measurements.
Following Screening of the Implants for the presence of landfill gasses, S&ME will perform a leak test by attaching
a brass T-connector to the end of polyethylene tubing and connecting a section of Teflon tubing to one part of
the T-connector and another section will be attached to a batch -certified, 1.4-liter summa canister. A plastic
shroud will be placed overtop the SAMPLE tubing array and summa canister. The other section of tubing from the
T-connector will be fitted through the shroud and attached to a helium detector. S&ME will then inject helium
(tracer) gas into the plastic shroud. The sampling array will be monitored for leaks by monitoring for the presence
of helium gas concentrations within the Teflon tubing. If the tracer gas is not detected through the sampling
array, then the sampling array will be considered leak free. If leaks are detected, the sampling array will be re -built
and re -tested for leaks. A schematic of the sample train is provided as Figure 2.
After successfully passing the leak test, the leak detection shroud will be removed, and three volumes of air will be
purged from the LFG sampling array using a calibrated low flow pump (similar to a personal air monitoring pump)
at a rate less than 200 milliliters per minute. After purging the sampling array, the valve to the 1.4-liter summa
canister will be opened to allow the collection of a LFG sample. The sample collection rate will be set with a three-
hour regulator. Blank field sampling forms are provided in Attachment II.
3.4 Laboratory Analysis:
Once the LFG samples are collected, the samples will be shipped under standard chain -of -custody protocol to a
qualified laboratory for analysis. The samples will be analyzed for:
Fixed Gases by EPA Method 3C (1-12, N2, 02, CO, CO2, CH4)
October 5, 2022 4
Work Plan for Landfill Gas Sampling
Duke Energy — McGuire Nuclear Station
Landfill No. 1 (Permit No. 6004-INDUS-1981)
wv:� S&ME Project No. 22350048
Sulfurs by EPA Method TO-15 Modified
After LFG samples are collected, S&ME will remove the sample tubing to approximately one foot below the top of
the ground surface and will fill the top of the boring with soil (note: the bore hole is filled with hydrated bentonite
clay mix). The location of the LFG implants will be recorded with a mapping grade sub -meter GPS unit.
4.0 Quality Assurance/Quality Control
4.1 Sampling Equipment
The direct push tooling will be decontaminated before and after visiting the site using an Alconox®/water soap
mixture and water rinse. A new, dedicated implant will be used for collecting each LFG sample. Dedicated Teflon -
lined tubing will be used in collection of the LFG samples. Summa canisters will be batch -certified and pre -
evacuated from the laboratory. Analytical documentation, demonstrating that the batch -certified summa
canisters are free of the target compounds down to the project reporting limits, will be obtained from the
laboratory, and provided in S&ME's report.
4.2 Sample Custody
The sampler will complete a chain -of -custody form provided by the laboratory. A blank chain -of -custody form
from the Enthalpy is included as Attachment III. The sampler will sign where indicated and record the site
identification, sample number, date and time of sampling, matrix code, sample type, bottle/preservative type, and
the analyses requested. When the custody of samples is transferred, the persons relinquishing and receiving
custody will sign, date, and record the time of transfer on the chain -of -custody. If the samples are shipped using
a commercial courier, the bill of lading will become part of the chain -of -custody and will serve as the signature of
the person receiving the samples. Upon receipt of the samples at the laboratory, a sample custodian will accept
custody of the sample and verify that the chain -of -custody is still intact. The laboratory will maintain the chain -of -
custody throughout the analytical and reporting processes. The laboratory will record the pressure upon arrival of
the summa canisters. If the initial vacuum prior to sampling is in excess of 10% lower than the vacuum
documented by the laboratory upon receipt, the cannister will not be used.
4.3 Laboratory Analytical Report
It is anticipated that routine analytical services will be provided by Enthalpy Analytical (Enthalpy) for this project.
The laboratories will provide Level II QA/QC analyses for this project, including the reporting of target analytes at
concentrations between the laboratory method detection limits and the laboratory reporting limits, otherwise
known as "J values". To the extent feasible, the laboratory method detection limits will not exceed the respective
regulatory standards.
5.0 Reporting
Following receipt of the laboratory analyses and results S&ME will prepare a report summarizing the results of the
LFG assessment. The final report will include the following:
October 5, 2022
Work Plan for Landfill Gas Sampling
.� Duke Energy — McGuire Nuclear Station
Z
Landfill No. 1 (Permit No. 6004-INDUS-1981)
S&ME Project No. 22350048
Narrative description of the sampling fieldwork;
Copies of field sampling forms, chain -of -custody forms, and QA/QC information;
Copy of lab data report;
Site plan showing sample locations;
Significant correspondence with the Section , if applicable;
Deviations, if any, from the Work Plan approved by the Section; and
Recommendations relative to the need for LFG vents and LFG monitoring after installation of the
geomembrane cover.
The report will be prepared under the supervision of a North Carolina Licensed Professional Geologist (PG), or
Professional Engineer (PE), and will bear both the firm PG/PE license numbers and individual license numbers and
seals.
6.0 References
Below is a chronological list of previous assessment reports, relevant to the McGuire Nuclear Station, which were
considered in preparing this assessment work plan.
May 21, 2021 — Site Characterization Report, prepared by Wood Group.
October 5, 2022
Figures
MCGUIRE
S
NUCLEAR
1
5
STATION
1{
1
II
}
1
SITE LOCATION
CL
a
1
♦
. _ - _ _ . _. _ R _ f_ _ .-_ . _ . _ . -
`_ __._._._._._`_
0 150 300 Feet
I � 1
—._.� Monitoring Wells
Property Boundary I— 250-ft Compliance Boundary Basal Saprolite/
Landfill Limit of Waste L Transition Zone Well
L_ _A OO Passive Soil Gas Sample Location Bedrock Well
I_ ! Review Boundary
Creeks/Streams Shallow Well
s ;
` R
S '�•y
Q5
• G
0 Trench Locations TOTAL VOC CONCENTRATIONS IN PSG SAMPLES
Total VOC Concentration (ug/L) AND SITE GEOPHYSICS
Geophysics - EM Response 6004-INDUS DUKE ENERGY CAROLINAS DUKE
Background Response High: 11.11 Notes: LANDFILL NO.1 (MCGUIRE)
Back ��
9 P PSG = Passive Soil Gas 4 ENERGY,
NS =Not Sampled MECKLENBURG COUNTY, NORTH CAROLINA
Elevated Response Low: 0.85 EM= Electromagnetic PROJECT NO: FIGURE NO:
Attachments
Attachment I
Implants Operation
from Geoprobe Systems®
www.geoprobe.com
1-800-436-7762
Attaching polyethylene tubing to the sampling implant.
The Tools for Site Investigation
Fi
Sampling Implants -Operation
Installation Instructions for Soil Gas Implants
1. Drive probe rods to the desired depth using a Point Holder
(AT-1313) and an Implant Anchor/Drive Point (PR-14). DO
NOT disengage the drive point when depth has been
reached.
2. Attach appropriate tubing to the implant (Figure 1).
If tubing is pre-cut, allow it to be approximately 48 in.
(1219 mm) longer than the required depth of the implant.
Cover or plug the open end of the tubing.
3. Remove pull cap and lower the implant and tubing down
inside the diameter of the probe rods until the implant hits
the top of the Anchor/Drive Point. Note the length of the
tubing to assure that proper depth has been reached.
4. Rotate tubing counterclockwise while exerting a gentle
downward force to engage the PRT threads (Figure 2). Pull
up on the tubing lightly to test the connection.
DO NOT cut excess tubing.
5. Position a Probe Rod Pull Plate or Manual Probe Rod Jack on
the top probe rod. Exert downward pressure on the tubing
while pulling the probe rods up. Pull up about 12 in. (305
mm).
6. If using 1/4-in. (6,4 mm) O.D. tubing or smaller, thread the
excess tubing through the Implant Funnel and position it
over the top probe rod. If using larger tubing, it may not be
possible to install the glass beads.
.w
Figure 1. Attaching tubing to the sampling
implant.
for
or
el)
Figure 2. Once depth is achieved, the
selected implant and tubing are inserted
through the rods. The tubing is rotated
to lock the implant into the drive point.
F.2
Sampling Implants - Operation
7. Pour glass beads down the inside diameter of the probe
rods around the outside of the tubing. Use the tubing to
"stir" the glass beads into place around the implant. Do not
lift up on tubing. It should take less than 150 mL of glass
beads to fill the space around the implant.
NOTE: Backfilling through the rods with glass beads or
glass beads/bentonite mixes can only be performed in the
Vadose Zone, not below the water table.
8. Lift up an additional 18 to 24 in. (457 to 610 mm) and pour
the bentonite seal mixture into place as in Step 7. The
volume to be filled is about 154 mL per foot. It may be
necessary to "chase" the seal mixture with distilled water to
initiate the seal.
16 Mesh 9• Pull the remaining rods out of the hole as in Step 5.
Bentonite Backfilling with sackcrete (cement/sand) or bentonite/sand
Chip may be done while removing the rods (Figure 4). If the PR-
14 Implant Anchor is used, the tubing may be cut flush with
the top probe rod and a regular pull cap may be used to
remove the remaining probe rods after Step 8.
Glass Bead
Figure 4. After the implant has been
secured, the rods are removed and
the annulus backfilled as appropri-
ate.
10. After the probe rods have been removed, cut the tubing at
the surface, attach a connector or plug, and mark the
location with a pin flag or stake. The point is ready for
sampling now.
r.
Figure 3. Glass Beads
create a permeable layer
around vapor sample
implants.
A vapor implant location.
The To•�ols for Site Investigation
,o.:. ': •,Q:. _.�J . /-�,- aQ:•. •' °".p;s..,',:•o,�:a,• .°:..xx:.q.:',,. A:.. oa f7.:;'.•':d`�::d:; `"���:�j::�:g:Q.:aP; •::;�1: - : �b�:o:
�.�qC]u, P.Qi,Q'.•. �.Ci"�'� �'S��'.� .�Y• �O�.i�..; ..0.• '`5�•..a•. .� ..Q.: ,•�`.: y 1
F.3
Sampling Implants -Operation
Capped End Pipe
Protector
Implant Funnel
Tubing
Implant
Glass Beads
Bentonite Mix
Seal Section
Implant
Backfill materials include glass Example of completed permanent
beads and bentonite sealants. soil gas monitoring point.
FA
NEENEIV-1. LANDFILL GAS SCREENING FORM
Meter Type/ Meter Name/ Serial No.:
Gas Analyzer GEM 5000 III
Project Name: Location:
NCDEQ ID No.: Date:
S&ME Project No.: Weather:
PID
Mini Rae 3000
Pre Calibration Time:
Task Order: S&ME Personnel:
Thermo Hygrometer
UEI OTH 10
Post Calibration Time:
PRE Equipment Calibration
Calibration Notes
POST Equipment Calibration
PID (Isobutylene)
0 ppm =
100 ppm =
PID (Isobutylene)
0 ppm =
100 ppm =
Fresh Air
CH4 (0%) =
02 (20.9%) =
Fresh Air
CH4 (0%) =
02 (20.9%) _
Methane High
CH4 (50%) =
CO2 (35%) =
Methane High
CH4 (50%) =
CO2 (35%) _
02 (0%) =
02 (0%)=
H25 Mix
CH4 (2.5%) =
02 (18%) =
H25 Mix
CH4 (2.5%) =
02 (18%) _
H2S (10 ppm) =
CO (50 ppm) =
H2S (10 ppm) =
CO (50 ppm) _
Screening Data
Sample Location
Time
VOCs
Methane
Carbon Dioxide
Oxygen
Hydrogen Sulfide
Barometric Pressure
Temperature
Humidity
ID
hr:min
ppm-v
%
volume in air (%)
% LEL
(100% LEL = 5%
CH4
%
%
ppm-v
in-Hg
°F
%
Name Signature Date Notes:
(1)
• •110 •�
Project Name: I I I
Project Number:
Location: Date:
Weather:
Air Temp ff):
Helium Detector Serial No.:
Calibration Date:
Sample Information
Sample Type
Sample ID
Canister ID
Regulator ID
Canister Volume (L)
Ambient Temp (°F)
Barometric Pressure (inHg)
Leak Test Information
Purge Method
He Concentration in Shroud N
He Detected in Leak Test (Y or N)
He Conc. Detected in Leak Test (ppm)
Percent of He in the Leak Test versus the
Shroud
Leak Test Passed (Yes/No)'
Purge Information
Enter
Construction Details
0.17" ID
Total Tubing
(ft)
0.25" ID
Total Tubing
(in)
Sand Pack
Interval
(in)
0.17" ID
Total Tubing
(ft)
0.25" ID
Total Tubing
(in)
Sand Pack
Interval
(in)
0.17" ID
Total Tubing
(ft)
0.25" ID
Total Tubing
(in)
Sand Pack
Interval
(in)
0.17" ID
Total Tubing
(ft)
0.25" ID
Total Tubing
(in)
Sand Pack
Interval
(in)
0.17" ID
Total Tubing
(ft)
0.25" ID
Total Tubing
(in)
Sand Pack
Interval
(in)
15
0
18
Sand Pack Interval Depth (in-bgs)
96
to
114
to
to
to
to
Volume (mL)
442
Purge Flow Rate (mL/min)
197
Purge Interval (3x Vol.) (min)
6.7
Actual Purge Time (min)
Sample Collection
Start Time
Initial Vacuum (inHg)
End Time
Final Vacuum (inHg)
Approximate Total Time (min)
Sample Analysis
Sampler Information
Sampled by: Sampler Signature: Date:
Notes: 1. Per the NCDEQ DWM VI Guidance dated March 2018, the helium concentration detected during the leak test shall not exceed 10% of the helium concentration in the shroud.
Revision Date: 5/3/1811:30
Attachment III
Air Chain of Custody Record
ENTHALP Lab NO:
I T I �C L Page: of
Turn Around Time (rush by advanced notice only)
Standard:
HDa
3 DayN
2 Day:
Custom TAT:
CUSTOMER INFORMATION
#N/A Company:
#N/A Report To:
PROJECT INFORMATION
Name:
Number:
Special Instructions: Email: P.O. #:
Address: Address:
Phone: Global ID:
Fax: Sampled By:
Analysis Requested
Type Equipment Information Sampling Information
(I) Indoor Size Flow Sample Sample vacuum Sample Sample vacuum
Sample ID (A)Ambient
(SV) Soil Vapor Canister ID (1L, 3L, Controller Start Start start End End End
(s)Source 6L, 15L) ID Date Time I Hg) Date Time I Hg)
1
2
3
4
5
6
7
8
9
10
Signature
Print
Name
Company/Title
Date / Time
1 Relinquished By:
1 Received By:
Z Relinquished By:
Z Received By:
3 Relinquished By:
3 Received By: