NCG140297_COMPLETE FILE - HISTORICAL_20070117

- STORMWATER-DIVISION CODING SHEET
RESCISSIONS.
PERMIT NO.
DOC TYPE
COMPLETE FILE - HISTORICAL
DATE OF
RESCISSION
❑ : � b ID D
YYYYMMDD

ROANOKE CHOWAN READY MIX, INC.,
108 WILLIFORD ROAD
AHOSKIE, NC 27910
JANUARY 12, 2007
JAN 17 Z007
®WQ-WARO
SUBJECT: PERMIT # NCG140297 RESPONSE TO
COMPLIANCE EVALUATION INSPECTION ON NOVEMBER 7,2006.
MR. AL HODGE, SUPERVISOR
SURFACE WATER PROTECTION SECTION
943 WASHINGTON SQUARE MALL
WASHINGTON, NC 27889
DEAR MR. HODGE:
Noj- 2oo�_PC-.00l�
WE HAVE DEVELOPED A STORMWATER POLLUTION PREVENTION PLAN. IT WAS
FAXED AND MAILED TO YOUR OFFICE ON 11/30/2006. IT IS BEING IMPLEMENTED AT THIS
TIME.
CONCRETE CONTAINMENT STRUCTURES HAVE BEEN SECURED BY FILLING THE
CRACKS WITH CONCRETE.
ON 11/16/2006 WE TOOK A SAMPLE (GRAB) OF STORMWATER RUN OFF AND HAD
IT TESTED BY ENVIRONMENT 1, INC., LOCATED IN GREENVILLE, NC. THE RESULTS WERE
INCLUDED WITH THE ABOVE MENTIONED CORRESPONDENCE. THE RESULTS HAVE BEEN
MAILED TO CENTRAL OFFICE AS MR WARREN RECOMMENDED TO US ON 1/12/2007.
WE ALSO HAVE IMPLEMENTED QUALATIVE MONITORING RECORDS FOR
STORMWATER DISCHARGE AREA. RECORDS OF DAILY RAINFALL AMOUNTS ARE BEING
RECORDED ALSO. RUN OFF AMOUNTS ARE BEING CALCULATED AND DOCUMENTED.
SECONDARY CONTAINMENT MONITORING INSPECTIONS ARE BEING DONE AND
DOCUMENTED.
FLOOR SWEEPINGS ARE BEING DEPOSITED IN PLASTIC BAGS, THE BAGS ARE
THEN KEPT IN PLASTIC 55 GALLON DRUMS UNTIL THEY CAN BE DISPOSED OF IN
LANDFILL. OIL FILTERS ARE ALLOWED TO DRAIN AND THEN PLACED IN PLASTIC BAGS
AND THEN IN PLASTIC DRUMS.
WE HAVE A COPY OF OUR PERMIT IN OUR FILES. WE ARE FOCUSING ON
UNDERSTANDING AND KNOWING WHAT OUR RESPONSIBILITIES ARE.

WE HOPE THAT THESE PROCEDURES AND POLICIES ARE IN COMPLIANCE WITH
DENR, DIVISION OF WATER QUALITY. PLEASE LET US KNOW OF ANY SUGGESTIONS YOU
MAY HAVE.
SINCERELY,
J GERALD WATERS
-2-

ROANOKE CHOWAN READY MIX, INC.,
108 WILLIFORD ROAD no ECENE©
AHOSKIE, N C 27910 W
DEC 0 7 2006
PERMITOYC.Q=14:029.7
NCDENR
943 WASHINGTON SQUARE MAUL
WASHINGTON, N C 27889
ATTENTION: MR. ED WARREN
DEAR MR. WARREN:
ENCLOSED YOU WILL FIND OUR STORMWATER POLLUTION
AND PREVENTION PLAN. PLEASE ADVISE OF ANY CHANGES
OR DEVIATIONS WE NEED TO MAKE. THANKING YOU
FOR YOUR TIME AND TROUBLE IN THIS MATTER.
YOURS TRULY.
GERALD WATERS

ROANOKE CHOWAN READY MIX, INC
108 WILLIFORD ROAD
AHOSKIE, NC 27910 ���',V'-_S�.I _ ,=
STORMWATER POLLUTION AND PREVENTION PLAN DEC 0 7 Z006
DW"'`J�9U uA E)
SITE PLAN. SEE ATTACHED MAP - A
(a) Receiving Waters: Stoney Creek, Latitude: +3613440, Longitude:
-07658140
(b) Potential pollutant sources list:
Bi Chemical containment structure
The following chemicals are stored in containment area:
Daracem 50 MSDS # D-06073
Darex II Aea MSDS # D-06007
Daraccel MSDS # D-06090
Daratard 17 MSDS $ D-05518
Size: 30.5 Feet X 11.33 Feet X 2.67 Feet
B2 Load out area & unloading area
B3 Rock storage area
B4 Wash area
B5 Containment pond
(c) Description of Storage practices;
Chemicals are stored in Bulk plastic tanks. The tanks are contained
in a cement block containment structure. Size 11.33' x 30.5',
depth 2.33' This containment structure is built on a 6" concrete
slab. Chemicals are pumped in by hose from delivery truck. They
are then pumped to load out by pipe into truck funnel.
Powdered cement is stored in metal tank 18' above ground level
The product is unloaded from delivery tanker to metal tank by
air pressure through pipes.
Rock is stored in bins comprised of concrete barriers. Water from
containment pond is pumped on rock occasionally. The liquid
runoff if any is directed back into containment pond. The rock and
sand is transferred by front end loader from storage area to
holding hopper. Then from hopper to batch plant and scales by
conveyor and to truck funnel by conveyor.
Powdered cement is dumped from metal tank directly to truck
funnel to eliminate dust.
Wash out. Well water is used to wash trucks off and wash out

trucks. The water is then directed into containment pond.
The washout area is less than 30 feet from pond to help contain
and direct the water to pond.
(d) Site Map. See attached site map. - B
A drainage furrow has been designed to run from batch house
(loading & unloading area) to containment pond. Also any run off
from rock and sand and storage area is directed in to this drain
furrow. The wash off area is also directed to this furrow. Stone
water that falls around potential pollutants is directed by furrow
to containment pond.
(e) There has been no reportable spills or leaks within the last three years.
Today's date 11/30/2006.
(f) Certification See attached results. Certification was done by Gerald
Waters.
2. STORMWATER MANAGEMENT PLAN.
(a) A ditch that runs along the southwestern boundary line
carries any storm water that is not susceptible to pollutant sources
to highway ditch that runs toward Stoney Creek. Storm water that
may come in contact with pollutant sources is directed to containment
pond drainage furrow.
(b) Chemical containment structure.
This structure is constructed so as to contain the liquid that would
come from a ruptured tank or spill. Storm water that accumulates
evaporates.
The metal tank that holds the powdered cement is constructed so that
no water will penetrate.
The containment pond has a clay bottom and sides. It also a 2 foot
berm surrounding it. The berm will allow pollutant source run off to
enter at one point. Size:
Solids that are removed from pond are piled with a berm around them.
After further solidifying the material is then distributed on faun paths.
These sites and accumulated waters are monitored at least 2 times
per year and documented for amount, color, foam, sheens, out fall
staining. Before any liquid is released test are run to determine that
they do not contain any pollutant and documented.
(C) Containment pond has a clay berm around the boundary
SPILL PREVENTION AND RESPOSE PLAN.
a

Inventories are kept daily on chemicals and powdered cement.
MSDS sheets are provided. See attached sheets. Ms. Linda
Williams is person that maintains these inventories and literature.
She monitors rain gauge and records rainfall for the facility.
She also performs a visual check of chemical containment structure.
PREVENTIVE MAINTENANCE AND GOOD HOUSEKEEPING.
Documentation of inspections and maintenance activities of
storm water control systems are maintained to ensure no contaminated
waters are released. The drainage furrow is kept open so water is directed
to containment pond.
5 & 6 EMPLOYEE TRAINING.
On October 3, 2006, during safety meeting, a spill response team was
appointed, Billy Downs, Jerome Watford, and Don Northcott.
Employees were informed of what the procedures to instigate in the event
of pollutant spill. Minutes of meeting are attached.
PLAN AMENDMENT.
If there is a change in design, construction or operation or
maintenance of this storm water plan, such changes are to be reviewed
and documented. This plan will be updated annually and dates of
any changes recorded. The Director will be notified in writing of any
changes.
3

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ROANOKE CHOWAN READY MIX INC.,
RAINFALL AMOUNTS
DATE
AMOUNT
RECORDED
TIME
STARTED
TIME
STOPPED
ESTIMATED
AMT TO
DISHARGE
37,500 FT'
ESTIMATED AMT
TO CONTAINMENT
POND 51,180 FT'
11/16/2006
1.8 INCHES
2:20 PM
7:15PM
5,625 FT'
7,677FT3
11/16/2006
1.6 INCHES
4:00 AM
3:15 PM
4,990 FT'
6,800 FT'
N

ENVIRONMENTAL EXPECTATIONS AND POLICY AND EMERGENCY
ACTION PLAN FOR VilAT EE-S AND VVAI RS- CON" I UC Y l ON
CONUMNV51INC. ANI .OA1` U T-KE, CHOVIA, N RF-EAD ' MU , ENC.
IT IS THE POLICY OF THIS COMPANTY TO PROTECT THE ENVIRONMENT OF
THE AREA WHERE WE ARE WORKING BY ABIDING BY ALL ENVIRONMENTAL
RULES AND REGULATIONS.
F',A RGE C T RLE SPONSE PLA,.NT I'(R l—L, ZA,-P-rj0PTJS M.A, PdllkL,S
SPILLS ---ANY UNPLANNED OR UNINTENTIONAL RELEASE OF A PETROLEUM
PRODUCT OR CHEMICAL ONTO THE GROUND OR WATER.
USE P'PE 'kv7j =TN CLEANING UP SPILLS
MOST SPILLS WILL INVOLVE FUEL OIL, MOTOR OIL OR HYDRAULIC OIL, LUBRICATION
GREASE, ETC. THE FOLLOWING ACTIONS WILL BE USED TO HANDLE LEAKS AND SPILLS
AND TO PREVENT ANY ENVIRONMENTAL DAMAGE.
DESIGNATED PERSONS WILL BE TRAINTED AS A FIRST RESPONSE TEAM. THESE PERSONS
ARE
TRAINING oVHLL INCLUDE CONTAINING SPILLS, CLEANINGS, RECOGNIZING
HAZARDS IN CLEAN UP AND LIMITS ON ABILITY TO CLEAN UP.
1. REPORT ANY LEAK OR SPILL TO AN IMMEDIATE SUPERVISOR
2. ALL SPILLS WILL BE DOCUMENTED AND CLEANED UP AS REQUIRED
3. STOP THE RELEASE IF YOU HAVE BEEN TRAINED TO DO SO AND IF FIRE AND
OTHER DANGERS DO NOT EXIST.
4. THE SPILL CLEAN UP TOOLS AND SUPPLIES CONSIST OF SHOVELS, SANTD, I=TY
LITTER, 0 _i, DRY, "DIAPERS", 3" K 48" BOOMS, POPE, PEGS, PUTTY, AND GLOVES.
AIND DISPOSAL BAGS WITH LABELS, AND SHOULD BE READILY AVAILABLE FOR
ALL SPILLS,
5. BUILD A SMALL EARTH DIKE AROUND IT IF NECESSARY
SPILLS THAT THREATEN LIVES OR HAVE SIGNIFICANT ENVIRONMENTAL THREAT MUST
BE REPORTED TO NC EMERGENCY MANAGEMENT AT 1-800-858-0368.
SPILL TO QUANTITY ACTION TO TAKE REPORT WITHIN 1 HOUR
�rJATL.I ANY VOLUXIE CONTAIN. CLEAN UP 18Q0-858-0368
CAUSII'vG A SI ETEN
Ord �r� ATER SURFACE
SOIL OVER 25 GALLOWS CONTAIN, CL.EA1_Y' UP 1-800-858-0368
WHEN TALIdNG TO NC EMERGENCY MANAGEMENT BE SURE TO:
1. GIVE GOOD DIRECTIONS TO SPILL SITE.
2. DO NOT HANG UP UNTIL DIRECTED TO DO SO.
3. RECORD THE NAME OF PERSON YOU SPEAK TO AND THE TIME.
4. WRITE A BRIEF REPORT INCLUDING CALLS MADE, PUBLIC AGENCY ANSWERS AND
RESPONSES, AND ACTIONS TAKEN BY YOU AND OTHER COMPANY EMPLOYE ES.
IF THE MATERIAL IS HAZARDOUS OR YOU DO NOT KNOW WHAT IT iS
1. DO NOT ATTEMPT CONTAINMENT OR CLEAN UP.
2. STAY A SAFE DISTANCE AWAY. ALLOW NO ONE TO ENTER THE AREA; USE
FLAGGING IF NECESSARY
3. LARGE VOLUMES OF GASOLLNTE OR OTHER VOLATILE SUBSTANCES SHOULD BE,
AVOIDED
4. CALL AND WAIT FOR FIRST RESPONSE TEAM.
m

SUGGESTIONS FOR SPILL PREVENTION
1. OVERNIGHT BULK STORAGE OF CHEMICALS AND PETROLEUM PRODUCTS
SHOULD BE AVOIDED.
2. PARKA -ND SECURE MACHINERY DURING NON -OPERATIONAL PERIODS SO THAT
RISK OF VANDALISM AND SPILLS ARE MINIMIZED
3. PROPERLY INSPECT AND MAINTAIN MECHANICAL EQUIPMENT
4. WHEN AT FIELD SITES, TAKE APPROPRIATE STEPS TO PREVENT SPILLS OF
PETROLEUM PRODUCTS WHEN PERFORMING SCHEDULED MAINTENANCE OR
REPAIRS ON MACHINERY
5. FOLLOW ALL APPLICABLE HAZARDOUS MATERIAL REGULATIONS
REQUIREMENTS FOR MOBILE TANKS TRANSPORTING HAZARDOUS MATERIALS.
MOBILE TANKS
1. TRUCKS, TRAILERS, OR PORTABLE TANKS MOUNTED IN VEHICLES:
2. COMPLY WITH ALLSTATE AND FEDERAL DOT REGULATIONS IN DESIGN,
CONSTRUCTION, LICENSING, PUBLIC SAFETY, INSPECTIONS, LABELING, AND
SHIPPING MANIFEST.
A. MOBILE TANKS 119 GALLONS OR LESS CAPACITY
1. PRODUCT LABELS.
B. MOBILE TANKS 119 GALLON CA2ACITY AND LARGER (TRAILERS OR
TRUCKS) REQUIRES:
1. CDL HAZ-MAT ENDORSEMENT FOR DRIVERS
2. LABELING
3. PLACARDS
4. VALVE PROTECTION DEVICES (GUARDS)
5. SHIPPING MANIFEST
C. ADDITIONAL REQUIREMENTS FOR TRAILERS
1. BRAKES ON ALL TRAILERS WITH GROSS WEIGHT OVER 3,000 LBS. (375
GALLONS)
2. LIGHTS
3. FENDERS
4. REFLECTIVE TAPE MARKINGS
5. PROPER COUPLING DEVICES WITH SAFETY CHAINS
FT71LD
1. ATTEMPT SUPPRESSION ONLY IF FIRE IS SMALL AND CAN BE EASILY CONTAINED.
2. CALL THE NORTH CAROLINA FOREST SERVICE FOR THE COUNTY YOU ARE IN.
COUNTY NC DIVISION OF FOREST RESOURCES
BEAUFORT
252-514-4764
BERTIE
252-331-4781
BLADEN
910-642-5093
BRUNSWICK
910-642-5093
CAMDEN
252-331-4781
CARTERET
252-514-4764
CHOWAN
252-331-4781
COLUMBUS
910-642-5093
CRAVEN
252-514-4764
CURRITUCK
252-331-4781
DARE
252-926-3041
DUPLIN
910-642-5093
in

DATE
ENVIRONMENTAL EXPECTATIONS, POLICY, AND EMERGENCY ACTION
PLAN. IT IS THE POLICY OF THIS COMPANY TO PROTECT THE
ENVIRONMENT OF THE AREA WHERE WE ARE WORKING BY ABIDING BY
ALL ENVIRONIi1ENTAL RULES AND REGULATIONS
WE, THE EMPLOYEES C T{' T'. 11 5 tLI Mj VV tip' E._ts CON STR UCITGN COMP 1K,
A:.l, r} R.Q-A-JqO '_L Cr:;O'FVA-N RI1_hDY TvfDL7, LNC., HAVE REVIEWED THE
EMERGENCY RESPONSE PLAN, THE OIL SPILL POLICY, WILDFIRES,
NATURAL DISASTER PROCEDURE, AND THREATENED AND ENDANGERED
SPECIES IN NORTH CAROLINA.
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ROANOKE CHOWAN READY MIX
RECORDS OF OBSERVATION OF SECONDARY CONTAINMENT
DATE
DONE BY
LOCATION, DESCRIPTION
COLOR
FOAM
OUT FALL STAINING
SHEENS
AMT.
RELEASED
IF ANY
DATE OF
RELEASE
11222006
G.WATERS
CONTAINMENT POND,
BLUE
NONE
NONE
NONE
NONE
N/A
11222006
G. WATERS
CHEM CONTAINMENT.
ACCUMULATED RAINWATER
CLEAR
NONE
NONE
NONE
NONE
N/A

Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Permit No.: N/C/_/_/_/_/_/_/_/ or Certificate of Coverage No.: N/C/G/ / / Lilt,/ d/ 5/ 7/
Facility Name: RDA/1,9K6 Glwa/At) R EAd r Mji ,-zNc
County: B ER t i oc Phone No. �Z,Sd - 83 :2- It u fl
Inspector:
Date of Inspection:
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
or
1. Outfall Description
Outfall No. Structure (pipe, ditch, etc.)
Receiving Stream: 5 TDA4 Y G R F— r- k
Describe the industrial activities that occur within the outfall drainage area:
FRRmzag
2. Color
Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint (light, medium,
dark) as descriptors: C /E A 2
3. Odor
Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak chlorine odor,
etc.) NoN F
4. Clarity
Choose the number which best describes the clarity of the discharge where 1 is clear and 10 is very
cloudy:
3 4 5 6 7 8 9 10
Page I
(I
SWU-242-101599

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:
0 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:
0 2 3 4 5 6 7 8 9 10
7. Foam
Is there any foam in the stormwater discharge? Yes V
8. Oil Sheen
Is there an oil sheen in the stormwater discharge? Yes No
9. Other Obvious Indicators of Stormwater Pollution
List and describe
Note: Low clarity, high solids, and/or the presence of foam or oil sheen may be indicative of pollutant
exposure. These conditions may warrant further investigation.
Page 2
W;
S W U-242-101599

ATA
NCDENR
DISCHARGE OUTFALL MONITORING REPORT
GENERAL PERMIT NCG140000
(All sample data shall be reported no later than 30 days after receipt of lab results)
Sample Information
.PermitTern
Yearapplicablesatnplingperiod�:
Year Stait/End Dates'
Place check inarkto indicate
.Discharge Type (check as appropriate)
Stormwater "'
"':Wastewater
I
August I, 2004 to July 31, 2005
❑
❑
91
❑
❑
❑
❑
®
❑
❑
❑
❑
❑
❑
❑
2
August I, 2005 to July 31 2006
3
August 1, 2006 to July 31, 2007
4
August 1, 2067 to July 31, 2008
5
August 1, 2008 to July 31 2009
Part A: Stormwater Discharge Monitoring Data (For stormwater not combined with process wastewater)
Storm Event Characteristics
Date':
- Total: Event `Preci itatimi inches _
_ .. Event Duration'.((hours)
//' /6- oG
�t s 55 lNu4es
Stormwater Discharge Monitoring
Does this facility perform Vehicle Maintenance Activities using on average more than 55 gallons of new motor
oil per month? ❑ Yes 1$ No If yes, complete information below.
Stormwater Discharge Monitoring from Vehicle Maintenance Areas
Outfall
Date: Sample,
;: Total Flow
Total Event
- Event'
'r , New :I:
pH ; ..
Total: ,
Oil :and( -
No.
Collected
Precipitation
'Duranon,,
'_Motoroils.'
Sucpeitded
Grease'
...
mo/dd `r
MG
inches "
hours
_ *al/mo}. _
: Std. Units
- - m I)
m l) ;
SWU-241-0&0104
Page loft
C3

Part B: Process wastewater discharge monitoring data
Sample #
Effluent Sotuc' s `for this sample
J
Vehicle / Equipment Cleaning
LiRaw
Material Stock -pile Wetting
❑
Mixing Drum Clean -out
❑
Recycle System Overflow
❑
Parameter
Unit
j Data
Collection Date
mo/dd/yr
Total Flow
MG
Event Duration
hours
OH ,
Std. units
TSS
mg/1
Settleable Solids
mul
Sample #
Effluent Sources forthis sam le ..'
Vehicle / Equipment Cleaning ❑
Raw Material Stock -pile Wettin ❑
Mixing Drum Clean -out ❑
Recycle System Overflow ❑
Parameter
-.--Unit..
Data '
Collection Date
mo/dd/yr
TotaCFlow
MG
Event Duration
hours
pli
Sid. units
TSS
mg/l
Settleable Solids
ml/I
Mail original and one copy to:
Attn: Central Files
Division of Water Quality
DENR
1617 Mail Service Center
Raleigh, NC 27699-1617
SWU-241-090104
Sample #
Effluent !Souice s for this sam le J
Vehicle / Equipment Cleaning ❑
Raw Material Stock -pile Wettin ❑
Mixing Drum Clean -out ❑
Recycle System Overflow ❑
Parameter;
"Umt ,
Data`
Collection Date
mo/dd/yr
Total;Flow-'
MG
Event Duration,
hours
P11
Std. units
TSS , -;,
mg/1
Settleable Solids
mVl
Sample # _
Effluent; Sources for this sain le ,
J
Vehicle / Equipment Cleaning
❑
Raw Material Stock -pile Wetting
❑
Mixing Drum Clean -out
❑
Recycle System Overflow
❑
Parameter..
Umt,
Data
Collection Date
mo/dd/yr
Total Flow `
MG
Event Duration ;
hours
Std. units
TSS°„..,
mg/1
Settleable Solids
mVl
"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 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. I am aware that there are significant penalties for submitting false
information, including the possibility of fines and imprisonment for knowing
violations."
6 2rA_Ld (//ATEi2S
(Print Name of Pernittee or Designee)
'D c,? 5 61- 30- ,0(,
(Signature of Perna tee or Designee) (Date)
Page 2 of 2
(q

Environment 1, Inc.
P.O. Box 7085. 114 Oakmont Dr.
Greenville. NC 27858
Phone [phone] • Fax [phone]
CLIENT:316 Week: 42
ROANOKE-CHOWAN READY NUX, INC.
108 WILLIFORD ROAD
AHOSKIE NC 27910
[phone]
CHAIN OF CUSTODY RECORD
Page _1_ of I
DISINFECTION
-------------
CHLORINE NEUTRALIZED AT COLLECTION
CHL0I2IN1
pH CHECK (LAB)
UV
CONTAINER TYPE, P!G
NONE
P
�
CHEMICALPRESERVATION
A
A - NONE D -NAOH
B-HNO, E -HCL
Z Z
rc 0
W Z
cc 0
U
w
z
a
µ, C-HzSO; F - ZINC ACETATE
U
O
U0
G
Q G- NATHIOSULFATE
pp
F U
U
C
2
I
CLASSIFICATION:
WASTEWATER(NPDES)
DRINKINGWATER
iDWQ/GW
t
SOLID WASTE SECTION
CHAIN OF CUSTODY MAINTAINED
DURING SH',r SENT/DELIVERY
>' N
SAMPLES C.-n ECTED BY.
(Please Print)
(rerAld W�TFR-S
(
SAMPLES RECEIVED IN LAB ATS�
REC /EDIBY(SIG.)
E
COMMENTS:
JDATE/TI
��
-t,EED BY ,"u.)
DATE/TIME
RECEIVED BY (SIG.)
DATETIME
Sampler must place a' C" for composite sample or a "G" for
Grab sample in the blocks above for each parameter requested.
FORM N5
Instructions for completing this form are on the reverse side.