NC0076643_Renewal (Application)_20200214

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ROY COOPER
Governor �. - ;;'`' �,
M[CHAEL S.REGAN ^m U..-
P'
Secretory � ` -`°'
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
February 17, 2020
General Electric Company
Attn: Bob Witsell, P.E.
1936 Redmond Or
Rome, GA 30165
Subject: Permit Renewal
Application No. NC0076643
Hickory Plant
Catawba County
Dear Applicant:
The Water Quality Permitting Section acknowledges the February 14, 2020 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting
branch. Per G.S. 150E-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit.The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deq.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
Sincerely
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
cc: Central Files w/application
ec: WQPS Laserfiche File w/application
DE -,`.'. North Caro9r Department of En 9renrrer.t_I Qn alitw I Divia n of Water Resooroas
N,�J�resvly R_o:oaal ff�a I n10 Ea"CenterAvenue,3izte3Oi I MooravJ:e,NorthCarolina28ii5
an::u.. •••���

Bob Witsell, P.E.
Brownfields Project Manager
GE
1935 Redmond Circle
Rome, GA 30165
USA RECEIVED
February 12, 2020
FEB 14 2020
NCDEQ, Division of Water Resources T+1 706 291 3319 NCDEQ/DWR/NPDES
NPDES Compliance & Expedited Permitting Unit F [phone]
1617 Mail Service Center [e-mail]
Raleigh, NC 27699
Re: Permit Application for Renewal of NPDES Permit No. NC0076643
GE Conover, NC Facility
Enclosed is a NPDES Permit Application for the renewal of NPDES Permit No. NC0076643. The current
permit was issued to the General Electric Company in Conover, NC for the discharge of water from a
groundwater remediation system. The existing permit expires on July 31, 2020.
The groundwater remediation system does not generate solids. Therefore, no sludge management plan is
required.
If you have any questions concerning this permit renewal application, please do not hesitate to contact me
at(706) 331-0347.
Sincerely,
Bob Witsell, P.E.
Brownfields Project Manager

NPDES PERMIT APPLICATION - SHORT FORM C - GW
For discharges associated with groundwater treatment facilities.
Mail the complete application to:
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
NPDES Permit Number NC0076643
If you are completing this form in computer use the TAB key or the up - down arrows to move from one
field to the next. To check the boxes, click your mouse on top of the box. Otherwise,please print or type.
1. Contact Information:
Owner Name General Electric Company
Facility Name General Electric Company- Hickory Facility RECEIVED
Mailing Address 1935 Redmond Circle FEB 14 2020
City Rome NCDEQ/DWR/NPDFS
State / Zip Code Georgia 30165
Telephone Number [phone]
Fax Number [phone]
e-mail Address [e-mail]
2. Location of facility producing discharge:
Check here if same as above ❑
Street Address or State Road 1223 Fairgrove Church Road
City Conover
State / Zip Code North Carolina 28613
County Catawba
3. Operator Information:
Name of the firm, consultant or other entity that operates the facility. (Note that this is not referring to the
Operator in Responsible Charge or ORC)
Name General Electric Company
Mailing Address 1935 Redmond Circle
City Rome
State / Zip Code Georgia 30165
Telephone Number [phone]
Fax Number [phone]
4. Ownership Status:
Federal ❑ State ❑ Private X Public ❑
Page I of 3 C-GW 6/17

NPDES PERMIT APPLICATION - SHORT FORM C - GW
For discharges associated with groundwater treatment facilities.
5. Products recovered:
Gasoline ❑ Diesel fuel ❑ Solvents X Other
6. Number of separate discharge points: 1
Outfall Identification number(s) 001
7. Frequency of discharge: Continuous X Intermittent ❑
If intermittent:
Days per week discharge occurs: Duration:
8. Treatment System Design flow 0.120 MGD
9. Name of receiving stream(s) (Provide a map showing the exact location of each outfall, including
latitude and longitude):
Unnamed Tributary of Cline Creek
10. Please list all additives to the treatment system, including chemicals or nutrients, that
have the potential to be discharged.
None
11. Is this facility located on Indian country? (check one)
Yes ❑ No X
12. Additional Information
All applicants (including renewals):
A USGS topographical map (or copy of the relevant portion) which shows all outfalls
A summary of the most recent analytical results (effluent data, if available) containing the
maximum values for each chemical detected
NEW Applicants only:
Engineering Alternative Analysis
Description of remediation treatment system components, capacities, and removal
efficiency for detected compounds.
If the g
treatments stem will discharge to a storm sewer, written approval from the
Y
municipality responsible for the sewer.
A list of any chemicals found in detectable amounts at the site, with the maximum
observed concentration reported for each chemical (the most recent sample must be
collected less than one year prior to the date of this application)
For petroleum-contaminated sites -Analyses for Volatile Organic Compounds (VOC) should
be performed. Analyses for any fuel additives likely to be present at the site and for phenol
and lead should also be performed.
For sites contaminated with solvents or other contaminants - EPA Method 624/625
analysis should be performed.
Page 2 of 3 C-GW 6/17

NPDES PERMIT APPLICATION - SHORT FORM C - GW
For discharges associated with groundwater treatment facilities.
13. Applicant Certification
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
Bob Witsell Brownfields Project Manager
g
Printed name of Person Signing Title
V l/ February 12, 2020
Signature of Applicant Date
North Carolina General Statute 143-215.6 (b)(2) provides that: Any person who knowingly makes any false
statement representation, or certification in any application, record, report, plan, or other document files or
required to be maintained under Article 21 or regulations of the Environmental Management Commission
implementing that Article, or who falsifies, tampers with, or knowingly renders inaccurate any recording or
monitoring device or method required to be operated or maintained under Article 21 or regulations of the
Environmental Management Commission implementing that Article, shall be guilty of a misdemeanor punishable
by a fine not to exceed $25,000, or by imprisonment not to exceed six months, or by both. (18 U.S.C. Section
1001 provides a punishment by a fine of not more than $25,000 or imprisonment not more than 5 years, or both,
for a similar offense.)
Page 3 of 3 C-GW 6/17

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General Electric Co., Hickory Facility Facility �,
Groundwater Remediation (GW-REM) Location . `� .-
Latitude: 35°42'22" Longitude: 81°15'37" not to scale ,
Quad/State Grid: Hickory,NC /EI3NE IIUC: 03050102
Receiving Stream: UT to Cline Creek Stream Segment: 11-129-5-2
Drainage Basin: Catawba River Basin Sub-Basin: 03-08-35 NPDES Permit NC0076643
Stream Class: C North
Catawba County

q Q n Pace Analytical Services,LLC
aceAnalytical 9800KineyAve. Suite78
Huntersville,NC 28078
www.pacelabs.com [phone]
November 19, 2019
Matthew
ARCADIS Pelton RECEIVED
5420 Wade Park Blvd Suite 350 FEB 14 2010
Raleigh, NC 27607 NCDEQ/DWR/NPDES
RE: Project: Influent Outfall Samples
Pace Project No.: 92453405
Dear Matthew Pelton:
Enclosed are the analytical results for sample(s) received by the laboratory on November 12, 2019.
The results relate only to the samples included in this report. Results reported herein conform to the
most current, applicable TNI/NELAC standards and the laboratory's Quality Assurance Manual,
where applicable, unless otherwise noted in the body of the report.
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
,,65,40ja J&
Bonnie Vang
[e-mail]
[phone]
Project Manager
Enclosures
cc: Chris Bagley,Arcadis
A_S�f
Z REPORT OF LABORATORY ANALYSIS
4 This report shall not be reproduced,except in full,
without the written consent of Pace Analytical Services,LLC. Page 1 of 12
•
6.

Pace Analytical Services,LLC
Analytical 9800 Kincey Ave. Suite 100
078
ace Analytical Huntersville,NC 28078
www.pacelabs.com [phone]
i
CERTIFICATIONS
Project: Influent Outfall Samples
Pace Project No.: 92453405
Pace Analytical Services Charlotte
9800 Kincey Ave.Ste 100,Huntersville,NC 28078 South Carolina Certification#:99006001
Louisiana/NELAP Certification#LA170028 Florida/NELAP Certification#:E87627
North Carolina Drinking Water Certification#:37706 Kentucky UST Certification#:84
North Carolina Field Services Certification#:5342 VirginiaNELAP Certification#:460221
North Carolina Wastewater Certification#:12
•
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services,LLC. Page 2 of 12

Pace Analytical Services,LLC
_ aceAnalytical 9800 Kincey Ave. Suite 100
Huntersville,NC 28078
www.pacelabs.com
r [phone]
SAMPLE ANALYTE COUNT
Project: Influent Outfall Samples
Pace Project No.: 92453405
Analytes
Lab ID Sample ID Method Analysts Reported Laboratory
92453405001 INFLUENT EPA 8260D CL 8 PASI-C
92453405002 OUTFALL EPA 8260D CL 8 PAST-C
92453405003 TRIP BLANK EPA8260D GAW 8 PASI-C
I
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services,LLC. Page 3 of 12

Pace Analytical Services,LLC
aceAnalytical 9800 Kincey Ave. Suite 100
Huntersville,NC 28078
/ www.pacelabs.com [phone]
ANALYTICAL RESULTS
Project: Influent Outfall Samples
Pace Project No.: 92453405
Sample: INFLUENT Lab ID: 92453405001 Collected: 11/12/19 12:00 Received: 11/12/19 13:23 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
8260D MSV Low Level Landfill Analytical Method:EPA 8260D
1,1-Dichloroethene ND ug/L 10.0 10 11/18/19 18:09 75-35-4
cis-1,2-Dichloroethene 259 ug/L 10.0 10 11/18/19 18:09 156-59-2
Tetrachloroethene 409 ug/L 10.0 10 11/18/19 18:09 127-18-4
Trichloroethene 1170 ug/L 10.0 10 11/18/19 18:09 79-01-6
Vinyl chloride ND ug/L 10.0 10 11/18/19 18:09 75-01-4
Surrogates
4-Bromofluorobenzene(S) 99 % 70-130 10 11/18/19 18:09 460-00-4
1,2-Dichloroethane-d4(S) 106 % 70-130 10 11/18/19 18:09 17060-07-0
Toluene-d8(S) 96 % 70-130 10 11/18/19 18:09 2037-26-5
Sample: OUTFALL Lab ID: 92453405002 Collected: 11/12/19 12:00 Received: 11/12/19 13:23 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
8260D MSV Low Level Landfill Analytical Method:EPA 8260D
1,1-Dichloroethene ND ug/L 1.0 1 11/18/19 17:18 75-35-4
cis-1,2-Dichloroethene ND ug/L 1.0 1 11/18/19 17:18 156-59-2
Tetrachloroethene ND ug/L 1.0 1 11/18/19 17:18 127-18-4
Trichloroethene ND ug/L 1.0 1 11/18/19 17:18 79-01-6
Vinyl chloride ND ug/L 1.0 1 11/18/19 17:18 75-01-4
Surrogates
4-Bromofluorobenzene(S) 99 % 70-130 1 11/18/19 17:18 460-00-4
1,2-Dichloroethane-d4(S) 107 % 70-130 1 11/18/19 17:18 17060-07-0
Toluene-d8(S) 97 % 70-130 1 11/18/19 17:18 2037-26-5
Sample: TRIP BLANK Lab ID: 92453405003 Collected: 11/12/19 00:00 Received: 11/12/19 13:23 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
8260D MSV Low Level Landfill Analytical Method:EPA 8260D
1,1-Dichloroethene ND ug/L 1.0 1 11/15/19 01:50 75-35-4
cis-1,2-Dichloroethene ND ug/L 1.0 1 11/15/19 01:50 156-59-2
Tetrachloroethene ND ug/L 1.0 1 11/15/19 01:50 127-18-4
Trichloroethene ND ug/L 1.0 1 11/15/19 01:50 79-01-6
Vinyl chloride ND ug/L 1.0 1 11/15/19 01:50 75-01-4
Surrogates
4-Bromofluorobenzene(S) 94 % 70-130 1 11/15/19 01:50 460-00-4
1,2-Dichloroethane-d4(S) 110 % 70-130 1 11/15/19 01:50 17060-07-0
Toluene-d8(S) 99 % 70-130 1 11/15/19 01:50 2037-26-5
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced.except in full,
Date: 11/19/2019 03:28 PM without the written consent of Pace Analytical Services,LLC. Page 4 of 12

Pace Analytical Services,LLC
ace Analytical 9800 Kincey Ave. Suite 100
Huntersville,NC 28078
www.pacelabs.com [phone]
QUALITY CONTROL DATA
Project: Influent Outfall Samples
Pace Project No.: 92453405
QC Batch: 509649 Analysis Method: EPA 8260D
QC Batch Method: EPA 8260D Analysis Description: 8260D MSV Low Level Landfill
Associated Lab Samples: 92453405003
METHOD BLANK: 2735246 Matrix: Water
Associated Lab Samples: 92453405003
Blank Reporting
Units Result Limit Analy
zed yzed Qualifiers
1,1-Dichloroethene ug/L ND 1.0 11/15/19 00:55
cis-1,2-Dichloroethene ug/L ND 1.0 11/15/19 00:55
Tetrachloroethene ug/L ND 1.0 11/15/19 00:55
Trichloroethene ug/L ND 1.0 11/15/19 00:55
Vinyl chloride ug/L ND 1.0 11/15/19 00:55
1,2-Dichloroethane-d4(S) % 106 70-130 11/15/19 00:55
4-Bromofluorobenzene(S) % 93 70-130 11/15/19 00:55
Toluene-d8(S) % 99 70-130 11/15/19 00:55
LABORATORY CONTROL SAMPLE: 2735247
Spike LCS LCS %Rec
Parameter Units Conc. Result %Rec Limits Qualifiers
1,1-Dichloroethene ug/L 50 53.6 107 70-130
cis-1,2-Dichloroethene ug/L 50 51.9 104 70-130
Tetrachloroethene ug/L 50 50.4 101 69-130
Trichloroethene ug/L 50 51.7 103 70-130
Vinyl chloride ug/L 50 54.9 110 70-131
1,2-Dichloroethane-d4(S) % 100 70-130
I 4-Bromofluorobenzene(S) % 99 70-130
Toluene-d8(S) % 103 70-130
MATRIX SPIKE SAMPLE: 2735249
92452862004 Spike MS MS %Rec
Parameter Units Result Conc. Result %Rec Limits Qualifiers
1,1-Dichloroethene ug/L ND 20 22.5 112 70-154
cis-1,2-Dichloroethene ug/L 0.98J 20 22.8 109 70-141
Tetrachloroethene ug/L ND 20 22.0 110 59-143
Trichloroethene ug/L ND 20 20.5 103 70-147
Vinyl chloride ug/L ND 20 23.8 119 70-156
1,2-Dichloroethane-d4(S) % 99 70-130
4-Bromofluorobenzene(S) % 100 70-130
Toluene-d8(S) % 96 70-130
SAMPLE DUPLICATE: 2735248
92452518010 Dup
Parameter Units Result Result RPD Qualifiers
1,1-Dichloroethene ug/L 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: 11/19/2019 03:28 PM without the written consent of Pace Analytical Services,LLC. Page 5 of 12

Pace Analytical Services,LLC
ace Analytical 9800 Kincey Ave. Suite 100
Huntersville,NC 28078
www.pacelabs.cam [phone]
QUALITY CONTROL DATA
Project: Influent Outfall Samples
Pace Project No.: 92453405
SAMPLE DUPLICATE: 2735248
92452518010 Dup
Parameter Units Result Result RPD Qualifiers
cis-1,2-Dichloroethene ug/L ND ND
Tetrachloroethene ug/L ND ND
Trichloroethene ug/L ND ND
Vinyl chloride ug/L ND ND
1,2-Dichloroethane-d4(S) % 107 109
4-Bromofluorobenzene(S) % 92 94
Toluene-d8(S) % 101 98
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: 11/19/2019 03:28 PM without the written consent of Pace Analytical Services,LLC. Page 6 of 12

Pace Analytical Services,LLC
ace Analytical 9800 KinceyAve. Suite 100
l� 1 1 li Huntersville,NC 28078
www pacelabs.com [phone]
QUALITY CONTROL DATA
Project: Influent Outfall Samples
Pace Project No.: 92453405
QC Batch: 510202 Analysis Method: EPA 8260D
QC Batch Method: EPA 8260D Analysis Description: 8260D MSV Low Level Landfill
Associated Lab Samples: 92453405001,92453405002
METHOD BLANK: 2737694 Matrix: Water
Associated Lab Samples: 92453405001,92453405002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
1,1-Dichloroethene ug/L ND 1.0 11/18/19 12:02
cis-1,2-Dichloroethene ug/L ND 1.0 11/18/19 12:02
Tetrachloroethene ug/L ND 1.0 11/18/19 12:02
Trichloroethene ug/L ND 1.0 11/18/19 12:02
Vinyl chloride ug/L ND 1.0 11/18/19 12:02
1,2-Dichloroethane-d4(S) % 98 70-130 11/18/19 12:02
4-Bromofluorobenzene(S) % 108 70-130 11/18/19 12:02
Toluene-d8(S) % 109 70-130 11/18/19 12:02
LABORATORY CONTROL SAMPLE: 2737695
Spike LCS LCS %Rec
Parameter Units Conc. Result %Rec Limits Qualifiers
1,1-Dichloroethene ug/L 50 46.3 93 70-130
cis-1,2-Dichloroethene ug/L 50 47.0 94 70-130
Tetrachloroethene ug/L 50 50.8 102 69-130
Trichloroethene ug/L 50 47.8 96 70-130
Vinyl chloride ug/L 50 48.9 98 70-131
1,2-Dichloroethane-d4(S) % 98 70-130
4-Bromofluorobenzene(S) % 99 70-130
Toluene-d8(S) % 99 70-130
MATRIX SPIKE&MATRIX SPIKE DUPLICATE: 2737696 2737697
MS MSD
92453405001 Spike Spike MS MSD MS MSD %Rec
Parameter Units Result Conc. Conc. Result Result %Rec %Rec Limits RPD Qual
1,1-Dichloroethene ug/L ND 200 200 214 209 107 104 70-154 3
cis-1,2-Dichloroethene ug/L 259 200 200 445 455 93 98 70-141 2
Tetrachloroethene ug/L 409 200 200 643 629 117 110 59-143 2
Trichloroethene ug/L 1170 200 200 1330 1380 78 103 70-147 4
Vinyl chloride ug/L ND 200 200 206 204 103 102 70-156 1
1,2-Dichloroethane-d4(S) % 98 96 70-130
4-Bromofluorobenzene(S) % 98 99 70-130
Toluene-d8(S) % 97 97 70-130
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: 11/19/2019 03:28 PM without the written consent of Pace Analytical Services,LLC. Page 7 of 12

Pace Analytical Services,LLC
aceAnalytical 9800 Kincey Ave. Suite 100
Hunlersville,NC 28078078
www.pacelabs.com [phone]
QUALIFIERS
Project: Influent Outfall Samples
Pace Project No.: 92453405
DEFINITIONS
DF-Dilution Factor,if reported,represents the factor applied to the reported data due to dilution of the sample aliquot.
ND-Not Detected at or above adjusted reporting limit.
TNTC-Too Numerous To Count
J-Estimated concentration above the adjusted method detection limit and below the adjusted reporting limit.
MDL-Adjusted Method Detection Limit.
PQL-Practical Quantitation Limit.
RL-Reporting Limit-The lowest concentration value that meets project requirements for quantitative data with known precision and
bias for a specific analyte in a specific matrix.
S-Surrogate
1,2-Diphenylhydrazine decomposes to and cannot be separated from Azobenzene using Method 8270.The result for each analyte is
a combined concentration.
Consistent with EPA guidelines,unrounded data are displayed and have been used to calculate%recovery and RPD values.
LCS(D)-Laboratory Control Sample(Duplicate)
MS(D)-Matrix Spike(Duplicate)
DUP-Sample Duplicate
RPD-Relative Percent Difference
NC-Not Calculable.
SG-Silica Gel-Clean-Up
U-Indicates the compound was analyzed for,but not detected.
Acid preservation may not be appropriate for 2 Chloroethylvinyl ether.
A separate vial preserved to a pH of 4-5 is recommended in SW846 Chapter 4 for the analysis of Acrolein and Acrylonitrile by EPA
Method 8260.
N-Nitrosodiphenylamine decomposes and cannot be separated from 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
PAST-C Pace Analytical Services-Charlotte
REPORT OF LABORATORY ANALYSIS
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Date: 11/19/2019 03:28 PM without the written consent of Pace Analytical Services,LLC. Page 8 of 12

Pace Analytical Services,LLC
aceAnalytical7
9800 Kincey Ave. Suite 100
Huntersville,NC 28078
www.pacelabs.com [phone] 11
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: Influent Outfall Samples
Pace Project No.: 92453405
Analytical
Lab ID Sample ID QC Batch Method QC Batch Analytical Method Batch
92453405001 INFLUENT EPA 8260D 510202
92453405002 OUTFALL EPA 8260D 510202
92453405003 TRIP BLANK EPA 8260D 509649
REPORT OF LABORATORY ANALYSIS
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Date: 11/19/2019 03:28 PM without the written consent of Pace Analytical Services.LLC. Page 9 of 12

Document Name: Document Revised:February 7,2018
e Sample Condition Upon Receipt(SCUR) Page 1 of 2
ace Analytical Document No.: Issuing Authority:
/ F-CAR•CS-033-Rev.06 Pace Carolinas Quality Office
Laboratory receiving samples:
Asheville❑ Eden[1] Greenwood❑ Huntersville ' Raleigh❑ Mechanicsville❑
1 I
Sample Condition Client Name l /
Upon ReceiptProject#: WO# : 92453405
n �� 1
Courier: ❑Fed,Ex ❑UPS ❑LISPSA. ❑Client III III I 11 1111111111
0 Commercial _lface ['Other:
92453405
Custody Seal Present? (]Yes i-- JNNo Seals Intact? Des jZiNo
Date/Initials Person Examining Contents: 7Lc-' -7-1 4 ( Cl
Packing Material: ❑Bubble Wrap E bble Bags :hone D Other Biological Tissue F zen?
Thermometer: Type of ice: ,ffwet ❑Blue ❑None Dyes OW/J
A
;24-Gun ID: `92T058
Cooler Temp(°C): J \ Correction Factor:Add/Subtract ) 0.0°C
t. Temp should be above freezing to VC
Cooler Temp Corrected('C): I ❑Samples out of temp criteria.Samples an ice,cooling process
has begun
USDA Regulated Sol N/A,water sample)
Did samples originate• a quarantine zone within the United States:CA,NY,or SC(check maps)? Dld samples originate horn a foreign source(internationally,
i Oyes ❑No Including Hawaii and Puerto Rico)?❑ves ❑No
Comments/Discrepancy:
Chain of Custody Present? yes ❑No ON/A 1. I
'
Samples Arrived within Hold Time? es ❑No ON/A 2.
Short Hold Time Analysis(<72 hr.)? Oven No ON/A 3.
Rush Turn Around Time Requested? Oyes two ON/A 4.
Sufficient Volume? ]Yes ❑No ON/A 5.
Correct Containers Used? es Elmo ON/A 6.
-Pace Containers Used? laves DAo ON/A
Containers Intact? ,Dyes ❑No ON/A 7. _--
Dissolved analysis:Samples Field Filtered? Des `6No ON/A 8.
Sample Labels Matun COC? pigs" ONo ON/A 9.
-Includes Date/Time/ID/Analysis Matrix: __V/ /
Headspace in VOA Vials(>5-6mm)? Des — ( ON/A 10.
Trip Blank Present? es )2No ON/A 11.
Trip Blank Custody Seals Present? press ❑No ON/A
COMMENTS/SAMPLE DISCREPANCY Field Data Required? Ekes ❑No
I containers:
Lot ID of split co :t s
CLIENT NOTIFICATION/RESOLUTION
•
Person contacted: _ Date/Time:
Project Manager SCURF Review: \\V Date: I t I \3 I i.
C
Project Manager SRF Review: Date: \ I `��I �,
Page 10 of 12

Document Name: Document Revised:February 7,2018
Sample Condition Upon Recelpt(SCUR) Page 1 of 2
ace Analytical' Document No.: Issuing Authority:
F-CAR-CS-033-Rev.06 Pace Carolinas Quality Office
*Check mark top half of box if pH and/or dechlorination is Project# WO#PM: BV : 92453405
verified and within the acceptance range for preservation Due Date: 11/19/19
samples.
Exceptions:VOA,Coliform,TOC,Oil and Grease,DRO/8015(water)DOC,LLHg CLIENT: 92-pRCADIS
"Bottom half of box Is to list number of bottle L 1
_ Z z
= a V Q 4 N z
4 u a Q i z a 2 °'
N
. riti S A
a . ? ZI N i Z r U ` t ` '5
v � n
' 2 x
cv u
Z ' S4t e
4q i z r�, « .�
g g . Si 2 O Q 3 c c O 4 E 2 0 1 z C c > i c c a
> > z a N Z Z 1O -z c U `rn' r 4 `n a o 1 a. o 7
C 2 = N Z 7 S .L U N C m �' M 1 W u .- A
'ill - �, E a o < < a < �, v E E a
A A '? Er. E
a. E. a n °' a J aJ E Q Q a Q `� O> O O> O Y` yt J N _, N 4
vE o 8E iv E c E v `w `u �`T,, Q! r�. E E E .2 1 1' of `z g a c
n N V1 ey ,,, N , « - S 9 o 0 V "" ,;; H N V- N rl N Q
= > > z N u u, nr t- 4 u t- t- U tt ar
E a rn r.1 .r t rn a a •• .+ m .� .n m g c4� t7 vt N
a a a a a a C. a V t9 W .9 W 0 8 3 0 X O - a o� ` m 4
m m m m o m m m 4 4 4 4 4 4 C > > G > > vt
1 Nillk
2
3 IMIIIIIhLXV , IlL X —
li
� I \ \
5 ,
6 ,
X . •\ -
: lIZLLILIML 1 I I 1.1k.\
1D 1 I I I I I I I I
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11 1 I I I I I I I I I I I I 6 k
-�_" _
12 . I L.. " \.\\
pH Adjustment Log for Preserved Samples
Sample ID Type of Preservative pH upon receipt Date preservation adjusted Time preservation Amount of Preservative Lot N
adjusted added
Note: Whenever there Is a discrepancy affecting North Carolina compliance samples,a copy of this form will be sent to the North Carolina DEHNR Certification Office(i.e.
Out of hold,incorrect preservative,out of temp,incorrect containers.
Page 11 of 12

CV
CHAIN-OF-CUSTODY/Analytical Request Document o
aCeAnalytcal The Chain-of-Custody is a LEGAL DOCUMENT.All relevant fields must be completed accurately. ot
a)
Section A Section B Section C ro
Required Client Information: Required Project Information: Invoice Information: Page: 1 Of 1
d
Company' Arcades-Raleigh,NC Report To RAY PENLEY HOLD FOR ARCADIS Attention
Address 2525 US Highway 70 SE Copy To Company Name
Hickory,NC 28602 Address. Regulatory Agency
Email Purchase Order# Pace Quote
Phone [phone] !Fax Project Name Influent Outfall samples Pace Project Manager bonnie.vang fpacelabs.corn. State/Location
Requested Due Date Project#. Pace Profile# 10403 NC
Requested Analysis Filtered(Y/N)
a 2
MATRIX CODE ii O COLLECTED = Preservatives >-
U O •
Dlmking Wale OW 13 U
Wale Wr W
Waste Water W _ Q W Z
SAMPLE ID Sono° .. C9 START END u i In F b m
w c"1
One Character per box. W P^ WP w oo Y o
An AR O Q m 01 Y Z L
# (A-Z,0-9 I:-1 Other OT w a eT a Z m �_
Sample Ids must be unique T,,,w. T, w w o N O r.. m g m
W a U a co O — O INv 2 r GC a 2 U w -7 i7 .-.
t— M 0 DATE TIME DATE TIME h a 0 I I `=�Z Z 2 0 1= 12 ~, 7C//
1 N1—/�,a✓i 6 !/ILl4 )% �; {/ L. Li(.
2 (9 _,=a-'-r— ;i G fl•ft-y 1OO 3 V - 0- L}
3 f ( J
4 I f
5
6
7
8
9
10
11
12
ADDITIONAL COMMENTS RELMOUISS�HED BY I AFFILIATION DATE - TIME ACCEPTED BY I AFFILIATION DATE TIME SAMPLE CONDI7i
1 az-r-4,7 G,= ittz-,,, 13)-ti ch 1� - ern,v%�t t-:Z- (11-/;- ! 3 S.`1 7 Y
SAMPLER NAME AND SIGNATURE
U o
PRINT Name of SAMPLER: c
m m
• a _m o m m... n�—
SIGNATURE of SAMPLER: I DATE Signed i/ /Z_ w ¢ m y rj fn v rn_y
2