NCG030466_MONITORING INFO_20191120

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PER NO.
�v C� 0-)
DOC TYPE.
❑ HISTORICAL FILE
t5-MONITORING REPORTS
DOC DATE
❑
YYYYMMDD

Stormwater Discharge Monitoring Report
for North Carolina Division of Energy, Mineral and Land Resources General Permit No. NCG030000
Date submitted
CERTIFICATE OF COVERAGE NO. N0003 0 L_I 6 6
FACILITYNAME FAT(1N coQPoRgTroN
COUNTY
PERSON COLLECTING SAMPLES U r
LABORATORYPALi: ANALyrfI A L. Lab Cert. # o
Comments on sample collection or analysis:
tv A
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR 2-6 19
SAMPLE PERIOD ❑ Jan -June �Dly-Dec
or ❑ Monthly' (month)
DISCFPP�NGR'f1,5� ORW ❑HQW ❑Trout ❑PNA
(( r ❑Zero -flow ❑Water Supply USA
NOV 2 2019 ❑other
CEPLEitS S BER TO SIGN ON PAGES 2 AND/OR 3 4
DWRS
❑ No discharge this period?'
Outfall No.
Date Sample
Collected'
(mo/dd/yr)
24-hour rainfall
amount,
Inches'
Total Suspended Solids
PH
Standard units
Total Copper
Total Lead
Total Zinc
Non -Polar O&G/
Total Petroleum
Hydrocarbons
Total Toxic
Organicss
Benchmarks
-
-
100 mg/L or 50 mg/O
6.0 - 9.0
0.010 mg/L
0.075 mg/L
0.126 mg/L
15 mg/L
1 mg/L
Parameter Code
-
46529
C0530
00400
01119
01051
01094
00552
78141
001
to go Ito 19
I.11
11 IL
6,39
0-0052 �J IL
40•00 S.JIL
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4,1-I•E-;Ic
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00 Z
10 30 .201'7
"
3 • 2 erb I
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44•005 IV It
0.02 .-)IL
c 4•ff � lL
rvA
OD �
7"
,2. 6 6
-43
1.0.005.y1L
ce•ooSAVIL
0•o284-JIL_
cIf. S 4- 1L
NA
o0 Lq
l0 ISO ,201
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Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outiali.
Z For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
'The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement.
"See General Permit, Section B, Table 1 to identify the especially sensitive receiving water classifications where the more protective benchmark applies.
s Total Toxic Organics sampling is applicable only for those facilities which perform metal finishing operations, manufacture semiconductors, manufacture
electronic crystals, or manufacture cathode ray tubes. For purposes of this permit the definition of Total Toxic Organics is that definition contained in the EPA
Effluent Guidelines for the facility subject to the requirement to sample (for metal finishing use the definition as found in 40 CFR 433.11; for semiconductor
manufacture use the definition as found in 40 CFR 469.12; for electronic crystal manufacture use the definition as found in 40 CFR 469.22; and for cathode ray
tube manufacture use the definition found in 40 CFR 469.31).
Permit Date: 11/1/2018-05/31/2021 SWU-245, last revised 11/1/2018
Page 1 of 3

Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan may so certify, and the requirement for TTO monitoring
may be waived. 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 electing to employ the TTO monitoring waiver, the discharger shall sign the following 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 the all the provisions of the
solvent management plan included in the Stormwater Pollution Prevention Plan."
Name (Print name)
E HS Mateo e,r�
Title (Print title)
Signature — Date
Note: Results must be reported in numerical format. Do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non -numerical
format. When results are below the applicable limits, they must be reported in the format. "<XX mg/L" where XX is the numerical value of the detection
limit, reporting limit, etc. in mg/L.
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
n Ain rlicrhnrno Chic norinr ;)2
Outfall No.
Date Sample Collected'
(mo/dd/yr)
24-hour rainfall amount,
Inches'
New Motor Oil or
Hydraulic Oil Usage
Non -Polar O&G/ Total
Petroleum Hydrocarbons
Total Suspended
Solids
Benchmarks
-
-
-
15 mg/L
100 mg/L or 50 mg/L4
Parameter Code
-
46529
NCOIL
00552
CO530
Footnotes from Part A also apply to Part B
Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text.
Permit Date: 11/l/2018-05/31/2021 SWU-245, last revised 11/1/2018
Page 2 of 3

FOR PART A AND PART B MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an oriainal copv of this DMR. including all "No Discharae" reports, within 30 days of receipt of the lab results (or at end of monitoring period in the
case of "No Discharge" reports) to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to
assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
0.0
Signature of Permittee
11 1-2. 2oi9,
Date
Permit Date: 11/1/2018-05/31/2021 -- - -- -- -_._ SWU-245, last revised 11/1/2018
----- ....------ ..
-- - -- - - - - - - - ------- - -- _- -'Page-3 of 3

i
aceAnalytical
www.pecela6s.com
November 08, 2019
Mark Buda
Eaton
221 Heywood Rd.
Arden. NC 28704
RE: Project: STORMWATER 10302019
Pace Project No.: 92451690
Pace Analytical Services, LLC
2225 Riverside Dr,
Asheville, NC 28804
[phone]
Dear Mark Buda:
Enclosed are the analytical results for sample(s) received by the laboratory on October 30, 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,
Chris Derouen
[e-mail]
[phone]
Project Manager
Enclosures
cc: Mark Buda, Eaton Corporation
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 1 of 14

aceAnalytical
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Project: STORMWATER 10302019
Pace Project No.: 92451690
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Charlotte Certification IDs
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
Louisiana/NELAP Certification # LA170028
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
Massachusetts Certification #: M-NC030
North Carolina Drinking Water Certification #: 37712
CERTIFICATIONS
South Carolina Certification #: 99006001
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
VirginiaNELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
VirginiaNELAP Certification #: 460222
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services, LLO, Page 2 of 14

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SAMPLE ANALYTE COUNT
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Project:
STORMWATER 10302019
Pace Project No.:
92451690
Analytes
Lab ID
Sample ID
Method
Analysts
Reported
Laboratory
92451690001
OUT 001
EPA 1664B
AAC1
1
PASI-C
EPA 200.7 Rev 4.41994
SHt
3
PASI-A
SM 2540D-2011
JP1
1
PASI-A
92451690002
OUT 002
EPA 1664B
AAC1
1
PASI-C
EPA 200.7 Rev 4.41994
SH1
3
PASI-A
SM 254OD-2011
JP1
1
PASI-A
92451690003
OUT 003
EPA 1664B
AACt
1
PASI-C
EPA 200.7 Rev 4.41994
SH1
3
PASI-A
SM 2540D-2011
JP1
1
PASI-A
92451690004
OUT 004
EPA 1664B
AAC1
1
PASI-C
EPA 200.7 Rev 4.4 1994
SH1
3
PASI-A
SM 254OD-2011
JP1
1
PASI-A
REPORT OF LABORATORY ANALYSIS
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aceAnalytical
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ANALYTICAL RESULTS
Project: STORMWATER 10302019
Pace Project No.: 92451690
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Sample: OUT 001 Lab ID: 92451690001 Collected: 10/30/19 13:30 Received: 10/30/19 16:02 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qua]
HEM, Oil and Grease
Oil and Grease
200.7 MET ICP
Copper
Lead
Zinc
2540D Total Suspended Solids
Total Suspended Solids
Analytical Method: EPA 1664E
NO mg/L
4.8 1
11/07/1910:00
Analytical Method: EPA 200.7 Rev 4.4
1994 Preparation
Method: EPA 200.7 Rev 4.4 1994
6.8 ug/L
5.0 1
10/31/19 23:17 11/07/19 01:06 7440-50-8
NO ug/L
5.0 1
10/31/19 23:17 11/07/19 01:06 7439-92-1
61.9 ug/L
10.0 1
10/31/19 23:17 11/07/19 01:06 7440-66-6
Analytical Method: SM 2540D-2011
17.5 mg/L
6.3 1
11/04/19 23:03
Sample: OUT 002 Lab ID: 92451690002 Collected: 10/30/19 13:30 Received: 10/30/19 16:02 Matrix: Water
Parameters Results Units Report Limit OF Prepared Analyzed CAS No. Qual
HEM, Oil and Grease
Oil and Grease
200.7 MET ICP
Copper
Lead
Zinc
2540D Total Suspended Solids
Total Suspended Solids
Analytical Method: EPA 1664B
ND mg/L
4.8
1
11/07/19 10:00
Analytical Method: EPA 200.7 Rev 4.4
1994 Preparation
Method: EPA 200.7 Rev 4.4 1994
ND ug/L
5.0
1
10/31/19 23:17 11/07/19 01:09 7440-50-8
ND ug/L
5.0
1
10/31/19 23:17 11/07/19 01:09 7439-92-1
20.0 ug/L
10.0
1
10/31/19 23:17 11/07/19 01:09 7440-66-6
Analytical Method: SM 254OD-2011
3.2 mg/L
2.5
1
11/04/1923:04
Sample: OUT 003 Lab ID: 92451690003 Collected: 10/30/19 13:30 Received: 10/30/19 16:02 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
HEM, Oil and Grease
Oil and Grease
200.7 MET ICP
Copper
Lead
Zinc
2540D Total Suspended Solids
Total Suspended Solids
Date: 11/08/2019 03:41 PM
Analytical Method: EPA 1664B
NO
mg/L
4.8
1
11/07/1910:00
Analytical Method:
EPA 200.7 Rev 4.4
1994 Preparation Method:
EPA 200.7 Rev
4.4
1994
ND
ug/L
5.0
1 10/31/19
23:17 11/07/19
01:12
7440-50-8
NO
ug/L
5.0
1 10/31/19
23:17 11/07/19
01:12
7439-92-1
28.4
ug/L
10.0
1 10/31/19
23:17 11/07/19
01:12
7440-66-6
Analytical Method:
SM 254OD-2011
2.6
mg/L
2.5
1
11/0411923:05
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services, LLC. Page 4 of 14

acleAnalyfical
wwwpacelabs.crom
ANALYTICAL RESULTS
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Project: STORMWATER 10302019
Pace Project No.: 92451690
Sample: OUT 004 Lab ID: 92451690004 Collected: 10/30/19 13:30 Received: 10/30/19 16:02 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
HEM, Oil and Grease
Analytical Method: EPA 1664B
Oil and Grease
ND mg/L
4.8 1
11/07/19 10:00
200.7 MET ICP
Analytical Method: EPA 200.7 Rev 4.4
1994 Preparation Method: EPA 200.7 Rev 4.4 1994
Copper
ND ug/L
5.0 1
10/31/1923*17 11/07/1901:21 7440-50-8
Lead
ND ug/L
5.0 1
10/31/1923:17 11/07/1901:21 7439-92-1
Zinc
34.2 ug/L
10.0 1
10/31/19 23:17 11/07/19 01:21 7440-66-6
2540D Total Suspended Solids
Analytical Method: SM 254OD-2011
Total Suspended Solids
3.6 mg/L
2.5 1
11/04/19 23:05
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 11/08/2019 03:41 PM without the written consent of Pace Analytical Services LLC. Page 5 of 14

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QUALITY CONTROL DATA
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Project: STORMWATER 10302019
Pace Project No.: 92451690
QC Batch: 508174
Analysis Method:
EPA 1664B
QC Batch Method: EPA 1664B
Analysis Description:
1664 HEM, Oil and Grease
Associated Lab Samples: 92451690001, 92451690002, 92451690003, 92451690004
METHOD BLANK: 2727919
Matrix: Water
Associated Lab Samples: 92451690001, 92451690002. 92451690003, 92451690004
Blank Reporting
Parameter
Units
Result Limit
Analyzed Qualifiers
Oil and Grease
mg/L
ND 4.8
11/07/19 10:00
LABORATORY CONTROL SAMPLE:
2727920
Spike LCS
LCS % Rec
Parameter
Units
Cone. Result
% Rec Limits Qualifiers
Oil and Grease
mg/L
38.5 32.2
84 78-114
MATRIX SPIKE SAMPLE:
2727921
92451190001 Spike
MS MS
% Rec
Parameter
Units
Result Cone.
Result % Rec
Limits Qualifiers
Oil and Grease
mg/L
ND 40
14.7 36
78-114 J(MI)
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: 11/08/2019 03:41 PM without the written consent of Pace Analytical Services, LLC.
Page 6 of 14

aceAnalytical
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QUALITY CONTROL DATA
Project: STORMWATER 10302019
Pace Project No.: 92451690
QC Batch:
507063
Analysis Method: EPA 200.7 Rev 4.4 1994
QC Batch Method: EPA 200.7 Rev 4.4 1994
Analysis Description: 200.7 MET
Associated
Lab Samples: 92451690001,
92451690002, 92451690003, 92451690004
METHOD BLANK: 2722680
Matrix: Water
Associated
Lab Samples: 92451690001,
92451690002, 92451690003, 92451690004
Blank Reporting
Parameter
Units
Result Limit
Analyzed Qualifiers
Copper
ug/L
NO 5.0
11/06/1923:44
Lead
ug/L
NO 5.0
11/06/1923:44
l Zinc
ug/L
NO 10.0
11/06/1923:44
Pace Ana lyticaI Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
LABORATORY CONTROL SAMPLE:
2722681
Spike
LCS
LCS
% Rec
Parameter
Units
Conic.
Result
% Rec
Limits Qualifiers
Copper
ug/L
500
480
96
85-115
Lead
ug/L
500
472
94
85-115
Zinc
ug/L
500
462
92
85-115
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2722682 2722683
MS MSD
92451277004 Spike Spike MS MSD MS MSD %Rec
Parameter Units Result Conic. Conc. Result Result %Rec %Rec Limits RPD Qual
Copper ug/L 296 500 500 777 808 96 102 70-130 4
Lead ug/L 108 500 500 564 575 91 93 70-130 2
Zinc ug/L 3020 500 500 3170 3220 29 40 70-130 2 J(M1)
I' MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2722684 2722685
MS MSD
i' 92451659002 Spike Spike MS MSD MS MSD e/ Rec
Parameter Units Result Conc Conc. Result Result e/ Rec %Rec Limits RPD Qual
Copper ug/L NO 500 500 479 487 96 97 70-130 2
Lead u9/1- ND 500 500 463 471 92 94 70-130 2
Zinc ug/L NO 500 500 460 468 92 93 70-130 2
Results presented on this page arc 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,
Dale: 11 /08/2019 03:41 PM without the written consent of Pace Analytical Services, L-C. Page 7 of 14

5OAnalytical
wwwpacelabs com
QUALITY CONTROL DATA
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Project: STORMWATER 10302019
Pace Project No.: 92451690
QC Batch: 507558
Analysis Method: SM 254OD-2011
QC Batch Method: SM 254OD-2011
Analysis Description: 2540D
Total Suspended
Solids
Associated Lab Samples: 92451690001,
92451690002,
92451690003, 92451690004
METHOD BLANK: 2724891
Matrix: Water
Associated Lab Samples: 92451690001,92451690002,92451690003,92451690004
Blank Reporting
Parameter
Units
Result Limit
Analyzed
Qualifiers
Total Suspended Solids
mg/L
ND 2.5
11/04/19 23:01
LABORATORY CONTROL SAMPLE & LCSD:
2724892
2724899
Spike LCS LCSD
LCS LCSD
% Rec Max
Parameter
Units
Conc, Result Result
% Rec % Rec
Limits RED RPD Qualifiers
Total Suspended Solids
mg/L
250 240 238
96 95
90-110 1 25
SAMPLE DUPLICATE: 2724900
92451703001 Cup
Parameter
Units
Result Result
RPD
Qualifiers
Total Suspended Solids
mg/L
229 186
21
Results presented on this page are in the units Indicated by the "Units" column except where au alternate unit is presenter) to the right or the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 11/08/2019 03:41 PM without the written consent of Pace Analytical Services, LLC.
Page 8 of 14

I
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Project:
Pace Project No.:
i, DEFINITIONS
STORMWATER 10302019
92451690
QUALIFIERS
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
DF - Dilution Factor, if reported, represents the factor applied to the reported data due to dilution of the sample aliquot.
NO - Not Detected at or above adjusted reporting limit.
TNTC - Too Numerous To Count
MDL-Adjusted Method Detection Limit.
POL- Practical Quantilation 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 Acrylonitnle 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
ANALYTE QUALIFIERS
J(M1) Estimated Value. Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS)
'I recovery.
1
REPORT OF LABORATORY ANALYSIS
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Date: 11/08/2019 03:41 PM without the written consent of Pace Analytical Services, LLC. Page 9 of 14

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QUALITY CONTROL DATA CROSS REFERENCE TABLE
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Project:
Pace Project 140:
STORMWATER 10302019
92451690
Analytical
Lab ID
Sample ID
QC Batch Method
QC Batch
Analytical
Method
Batch
92451690001
OUT 001
EPA 1664E
508174
92451690002
OUT 002
EPA 1664B
508174
92451690003
OUT 003
EPA 1664E
508174
92451690004
OUT 004
EPA 1664B
508174
92451690001
OUT 001
EPA 200.7 Rev 4.4 1994
507063
EPA 200.7
Rev 4.4 1994
507076
92451690002
OUT 002
EPA 200.7 Rev 4A 1994
507063
EPA 200.7
Rev 4.4 1994
507076
92451690003
OUT 003
EPA 200.7 Rev 4.4 1994
507063
EPA 200.7
Rev 4.4 1994
507076
92451690004
OUT 004
EPA 200.7 Rev 4.4 1994
507063
EPA 200.7
Rev 4.4 1994
507076
92451690001
OUT 001
SM 2540D-2011
507558
92451690002
OUT 002
SM 2540D-2011
507558
92451690003
OUT 003
SM 2540D-2011
507558
92451690004
OUT 004
SM 254OD-2011
507558
Date: 11/08/2019 03:41 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC,
Page 10 of 14

Document Name: Document Revised: February 7, 2018
Sample Condition.Upon Receipt(SCUR) Page 1 of2
ACeilnalXICc7( DocumentNo.: Issuing Authority`:
F-CAR-CS-033-Rev.06 Pace Carolinas Quality Office
Laboratory receiving sa ples:
Ashevill& Eden❑ Greenwood Huntersville❑ Raleigh[] Mechanicsville❑
Client Name: W®# 92451690
Courier: ❑Fed Ex ❑UPS CUSPS / noject #; I IIVII� IOl IIII�I��II �II
❑te Commercial -Spa//'W/jJ�DI%R ❑Other L92451
Custody Seal Present? ❑Yes "EINo Seals Intact? Des r[i]No
Date/Initials Person Examining Contents:
Packing Material: ❑Bubble Wrap `❑Bubble Bags ❑None ❑ Other Biological Tissue F7zen?
Thermomet _ [:]yes❑No�N/A
��rr 93TO6� Type of Ice: c❑V�t ❑Blue ❑FIPna
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Did samples originate in a quarantine zone within the United States: CA, NY, q'r Sc (check maps)?. Did samples originate from a foreign source (Internationally,
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Short Hold Time Analysis(472 hr.)?
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Containers Intact?
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Dissolved analysis: Samples Field Filtered?
Sample Labels Match COO
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COMMENTS/SAMPLE DISCREPANCY
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Page 11 of 14

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Document Name:
Sample Condition Upon Receipt(SCUR)
Document Revised: February 7, 2018
Page 1 of 2
Document No.:
F-CAR-CS-033-Rev.06
Issuing Authority:
Pace Carolinas Quality Office
*Check mark top half of box if pH and/or dechlorination is
verified and within the acceptance range for preservation
samples.
Exceptions: VOA, Coliform, TOC, Oil and Grease, DRO/8015 (water) DOC, LLHg
**Bottom half of box is to list number of bottle
Project; W®# : 92451690
PM: CDl Due Date: 11/13/19
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Note: Whenever there is a discrepancy affecting North Carolina compliance samples, a copy of this form will be sent to the North Carolina DEN NR Certification Office (i.e.
Out of hold, incorrect preservative, out of temp, incorrect containers.
Page 12 of 14

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