NCG030513_MONITORING INFO_20190717

STORMWATER DIVISION CODING SHEET ,
NCG PERMITS
PERMIT NO.
5/ 3
w LC 050
DOC TYPE.
❑ HISTORICAL FILE
9 MONITORING REPORTS
DOC DATE
❑ a � � V7 /
YYYYM M DD

m
GOOD j YEAR
The Goodyear Tire & Rubber Company — Statesville Mold Plant
108 Business Park Drive
Statesville, NC 28677
July 9, 2019
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
RE: Storm Water DMR, General Permit NCG030000, COG NCG030513
Dear Mr. or Ms.,
The Goodyear Tire & Rubber Company — Statesville Mold Plant is covered under North Carolina General Storm
Water Permit NCG030000. The permit requires submission of a discharge monitoring report within 30-days of
receiving analytical results.
Please find enclosed a DMR for a sample from June 12, 2019 from outfall #1.
If further information is required please do not hesitate to contact me at 704-928-4505.
Sincerely,
41cholas Fugitt
Quality Manager
The Goodyear Tire & Rubber Company
RF0'
Certified Mail No. 7014 2120 0000 7370 5832 ✓&4 'F/l/je;
Return Receipt Requested C I7
OS'tiikq Z�j9
Attachment
SFCTFOES
cc: file

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Stormwater Discharge Monitoring Report
for North Carolina Division of Energy, Mineral and Land Resources General Permit No. NCG030000
CERTIFICATE OF COVERAGE NO. NCG03 0 5
FACILITY NAME Goodyear Tire & Rubber Co -Statesville
COUNTY Iredell
PERSON COLLECTING SAMPLES Nicholas
LABORATORY Pace Analytical Services LLC Lab Cert. # 12
Comments on sample collection or analysis:
Date submitted 7/9/2019
% SAMPLE COLLECTION YEAR 2019
SAMPLE PERIOD Q Jan -June ❑ July -Dec
or ❑ Monthly' (month)
DISCHARGING TO CLASS ❑ORW ❑HQW []Trout ❑PNA
❑Zero -flow []Water Supply ❑SA
*Other class c
Part A: Stormwater Benchmarks and Monitoring Results
PLEASE REMEMBER TO SIGN ON PAGES 2 AND/OR 3 4
n No discharge this period?'
Outfall No.
Date Sample
Collected'
(mo/dd/yr)
24hour rainfall
amount,
Inches'
Total Suspended Solids
pH,
Standard units
Total Copper
Total Lead
Total Zinc
Non -Polar O&G/
Total Petroleum
Hydrocarbons
Total Toxic
Organics
Benchmarks
-
-
100 mg/L or 50 mg/1.4
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
Ouffall 1 Pond
06/12/19
1.25 inch
3.8 mg/L
6.44
<0.005 mg/L
<0.005 mg/L
0.028 mg/L
<4.8 mg/L
NA
' Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
a 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.
5 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 Stormlwater Pollution Prevention Plan."
k W Fit Vyt I l ► ez-
Name (Pri6t name)
Ma,n ttt� d-yv-I'tna, IQI'r-ea�✓' .
Title (Print title)
Signature Ll 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.
❑ No discharge this periodj2
Outfatl 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 SO 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: 11/1/2018-05/31/2021 SWLI-245, last revised 11/1/2018
Page 2 of 3

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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 ANY ONE OUTFALL? YES [I NO E]
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an oriainal copv of this DMR, includina all "No Discharge' reports within 30 days of receipt of the lab results for 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."
Date
Permit Date: 11/1/2018-05/31/2021 SWU-245, last revised 11/1/2018
Page 3 of 3

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June 26, 2019
Nicholas Fugitt
Goodyear
108 Business Park Drive
Statesville, NC 28677
RE: Project: STORMWATER 6/12
Pace Project No.: 92432972
Pace Anslytkal Services, LLC
98001(incey Ave. Suite too
Huntersville, NC 28078
[phone]
Dear Nicholas Fugitt:
Enclosed are the analytical results for sample(s) received by the laboratory on June 13, 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
EnGosures
elao
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 13

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Project: STORMWATER 6112
Pace Project No.: 92432972
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 M 12
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
Flonda/NELAP Certification M E87648
Massachusetts Certification #: M-NC030
North Carolina Drinking Water Certification M 37712
CERTIFICATIONS
South Carolina Certification M 99006001
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
VrginiaNELAP Certification M 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
vrginiaNELAP Certification M 460222
REPORT OF LABORATORY ANALYSIS
Pace Analytical Services, LLC
980010ncey Ave. Suite 100
Huntesville, NC 28078
[phone]
This report shall not be reproduced, except in full,
without the written consent of Pecs Analytical Services, LLC. Page 2 of 13

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SAMPLE ANALYTE COUNT
Pace Analytical Services, LLC
9800 loncey Ave. Suite 100
Huntersville, NC 28078
(704)8759092
Project:
Pace Project No.:
STORMWATER 6/12
92432972
Analytts
Lab ID
Sample ID
Method
Analysts
Reported
Laboratory
92432972001
GOODYEAR
EPA 1664B
JMS
1
PASI-C
EPA 1664B
JMS
1
PASI-C
EPA 200.7 Rev 4.4 1994
DS
3
PASI-A
SM 254OD-2011
MJP
1
PASI-A
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC. Page 3 of 13

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ANALYTICAL RESULTS
Pace Analytical Services, LLC
980010ncey Ave. Suite 100
Humersville, NC 28078
[phone]
Project: STORMWATER 6/12
Pace Project No.: 92432972
Sample: GOODYEAR Lab ID: 92432972001 Collected: 06/12/19 21:10 Received: 06113119 08:51 Matrix: Water
Parameters Results Units Report Limit OF Prepared Analyzed CAS No. Oual
HEM, Oil and Grease
Analytical Method: EPA 1664B
Oil and Grease
NO mg/L
4.8
1
06126119 06:32
1664 SGT-HEM, TPH
Analytical Method: EPA 1664B
Total Petroleum Hydrocarbons
NO mg/L
4.8
1
06/26/19 06:32
200.7 MET ICP
Analytical Method: EPA 200.7 Rev 4.4
1994 Preparation Method: EPA 200.7 Rev 4.4 1994
Copper
NO ug/L
6.0
1
06/22/19 00:46 06/23/19 02:45 7440-50-8
Lead
NO ug/L
5.0
1
06/22/19 00:46 06/23/19 02:45 7439-92-1
Zinc
28.3 ug/L
10.0
1
06/22/19 00:46 06123119 02:45 7440-66-6
2540D Total Suspended Solids
Analytical Method: SM 254OD-2011
Total Suspended Solids
3.8 mg/L
2.6
1
D6/18119 13:29
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 06/26/2019 04:46 PM without the written consent of PaosAnaytical Services, U.C.
Page 4 of 13

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QUALITY CONTROL DATA
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntenville, NC 28078
[phone]
Project:
STORMWATER 6112
Pace Project No.:
92432972
QC Batch:
483274 Analysis Method: EPA 1664B
QC Batch Method:
EPA 1664E Analysis Description: 1664 HEM, Oil and Grease
Associated Lab Samples: 92432972001
METHOD BLANK: 2612197
Associated Lab Samples: 92432972001
Parameter Units
Oil and Grease mg/L
Matrix: Water
Blank Reporting
Result Limit Analyzed Qualifiers
ND 4.8 06/26/19 06:32
LABORATORY CONTROL SAMPLE:
2612198
Spike
LCS
LCS
% Rae
Parameter
Units
Cone.
Result
% Rae
Limits
Qualifiers
Oil and Grease
mg/L
38.5
37.2
97
78-114
MATRIX SPIKE SAMPLE:
2612199
92433383001 Spike
MS
MS
%Rec
Parameter
Units
Result
Conc.
Result
%Rec
Limits Qualifiers
Oil and Grease
mg/L
NO 38.5
37.4
97
78-114
Resuae pnwnted on M4 pope an in Me unit, Inmcated by the'UnW column except whom an aaerrufa unit b presentee to the dpM of tiu nmult.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 061262019 04:46 PM without the written consent of Pew Analytical Services, L-C.
Page 5 of 13

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QUALITY CONTROL DATA
Pece AnsWal Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Project:
STORMWATER 6/12
Pace Project No.:
92432972
QC Batch:
483275 Analysis Method: EPA 1664E
QC Batch Method:
EPA 1664E Analysis Description: 1664 SGT-HEM, TPH
Associated Lab Samples: 92432972001
u1�CLeLl:1t►_1.13i'd.4iF4'Zrh 'F.TG'Pi•'JF.TiS
Associated Lab Samples: 92432972001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Petroleum Hydrocarbons mg/L NO 4.8 06126/19 06:32
LABORATORY CONTROL SAMPLE:
2612201
Spike
LCS
LCS
% Rec '
Parameter
Units
Conc.
Result
%Rec
Limits
Qualifiers
Total Petroleum Hydrocarbons
mg/L
19.2
20.9
108
64-132
MATRIX SPIKE SAMPLE:
2612202
92433383001 Spike
MS
MS
% Rec
Parameter
Units
Result
Conc.
Result
%Rec
Limits Qualifiers
Total Petroleum Hydrocarbons
mg/L
ND 19.2
21.1
108
64-132
Results praeMed on this papa am in the unite Inmcats4 by the'UnW column swap sMem an aasmate uNt Is pmeemed to the dpM of the result
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 06/26/2019 04:46 PM without the written consent of Pace Analytical Services, L-C. Page 6 of 13

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QUALITY CONTROL DATA
Pace Ana"cal Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704)8759092
Project:
STORMWATER 6/12
Pace Project No.:
92432972
OC Batch:
482699 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: 92432972001
METHOD BLANK: 2609749 Matrix: Water
Associated Lab Samples: 92432972001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Copper ug/L NO 5.0 06/23/19 01:54
Lead ug/L NO 5.0 06/23/1901:64
Zinc ug/L NO 10.0 06/23/19 01:54
LABORATORY CONTROL SAMPLE:
2609750
Spike
LCS LCS
% Rae
Parameter
Units
Cone.
Result % Rae
Limits Qualifiers
Copper
ug/L
500
495 99
85-115
Lead
ug/L
500
472 94
85-115
Zinc
ug/L
500
474 95
85-115
MATRIX SPIKE & MATRIX SPIKE DUPLICATE:
2609751
2609752
MS
MSD
92432800001
Spike
Spike
MS
MSD
MS
MSD
%Rec
Parameter
Units
Result
Cone.
Cone.
Result
Result
%Rec
%Rec
Limits RPD Qual
Copper
ug/L
NO
500
500
539
545
108
109
70-130 1
Lead
ug/L
9.6
500
500
488
494
96
97
70-130 1
Zinc
ug/L
682
500
500
1190
1200
102
104
70-130 1
MATRIX SPIKE & MATRIX SPIKE DUPLICATE:
2609753
2609754
MS
MSD
92432972001
Spike
Spike
MS
MSD
MS
MSD
%Rec
Parameter
Units
Result
Cone.
Cone.
Result
Result
% Rae
% Rae
Limits RPD Qual
Copper
ug/L
NO
500
500
503
497
100
99
70-130 1
Lead
ug/L
ND
Soo
500
482
473
96
95
70-130 2
Zinc
ug/L
28.3
500
500
518
510
98
96
70-130 2
Reaves presanted on this page am In the units IncDcated by the-Units' column except ednn an anemab unit is presented to the right otow, raardt.
REPORT OF LABORATORY ANALYSIS
This report shell not be reproduced, except in full,
Date: 06/26/2019 04:46 PM without the written consent of Pam Analytical Services, L-C.
Page 7 of 13

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QUALITY CONTROL DATA
Project: STORMWATER 6/12
Pace Project No.: 92432972
QC Batch: 481765 Analysis Method: SM 254OD-2011
QC Batch Method: SM 254OD-2011 Analysis Description: 2540D Total Suspended Solids
Associated Lab Samples: 92432972001
METHOD BLANK: 2605346 Matrix: Water
Associated Lab Samples: 92432972001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Suspended Solids mg/L NO 2.5 06/18/19 13:26
Pace Analytical Services, LLC
9a00 Kincsy Ave. Suhe 100
Humersville, NC 28078
[phone]
LABORATORY CONTROL SAMPLE:
2605347
Spike
LCS LCS % Rec
Parameter
Units
Cone.
Result % Rae Limits Qualifiers
Total Suspended Solids
mg/L
251
248 99 90-110
SAMPLE DUPLICATE: 2605348
92432875002 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 173 175 1
SAMPLE DUPLICATE: 2605349
92433030001 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 107 109 2
Resuhs pnseded en Mls pegs am In i o I�catsd by ifm'UN ' cdumn except when m al s im a un t Is pre enW to Me nets ortte rerun.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 06126/2019 04:46 PM without the written consent of Pace Analytical Services, L-C.
Page 8 of 13

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QUALIFIERS
Project: STORMWATER 6/12
Pace Project No.: 92432972
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.
Pace Analytical Services, LLC
9800 Kinsey Ave. Suite too
Hunteniville, NC 28078
[phone]
PQL - Practical Quantitabon 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 analyle 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 ofAcrolein and Acrylonitrile by EPA
Method 8260.
N-Nitrosodiphenylamine decomposes and cannot be separated from Diphenylamine using Method 8270. The result reported for
each anayte is a combined concentration.
Pace Analytical is TNI accredited. Contact your Pace PM for the current list of accredited anatytes.
TNI - The NELAC Institute.
LABORATORIES
PAST -A Pace Analytical Services -Asheville
PASI-C Pace Analytical Services - Charlotte
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 06/26/2019 04:46 PM without the written consent of Pace Analytical Services, LLC. Page 9 of 13

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QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: STORMWATER 6/12
Pace Project No.: 92432972
Lab ID
Sample ID
QC Batch Method
QC Batch
92432972001
GOODYEAR
EPA 1664E
483274
92432972001
GOODYEAR
EPA 1664E
483275
92432972001
GOODYEAR
EPA 200.7 Rev 4.4 1994
482699
92432972001
GOODYEAR
SM 254OD-2011
481765
Date: 06/26/2019 04:46 PM
REPORT OF LABORATORY ANALYSIS
This report shall not he reproduced, except in full,
wiMout the written consent of Pace Analytical Services, LLC.
Paco Analytical Services, LLC
980016ncey Ave. Suhe 100
Huntersville, NC 28078
(704)8759092
Analytical Method
Analytical
Batch
EPA 200.7 Rev 4.4 1994 482713
Page 10 of 13

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Document Name:
Sample Condition Upon Recei t SCUR
Document Revised: February 7, 2018
Page 1 of 2
Document No.:
F-CAR-CS-033.0— ru;
Issuing Authority:
Pace Carolinas Quality Office
Laboratory receiving samples:
Asheville ❑ Eden[] Greenwood ❑ Huntersville,e Raleigh❑ Mechanicsville[]
client Name:
W®# ' 92432972
i ' Project
Hill II H I II I II II I OII
Courier: ❑Fe Ex ❑U S ❑USPS BElient
❑ Commercial []Pace ❑Other:_
92432972
��'' //
Custody Seal Present? ❑Yes j_JNo Seals Intact? []Yes ❑No
• �' � Li
Date/Innials Perron Examining Contents: yI
Packing Material: ❑Bubble Wrap Z Bubble Bags []None ❑ Other
Biological Tissue Frozen?
[]Yes []No ,84/A
Thermometer•
IRGunlo: 92TO48 Type of ice: wet ❑Blue
❑None
Cooler Temp('C): 1, LI. Correction Factor:Add/Subtract ('q 0.0
Temp should be above freezing to 6'C
Cooler Temp Corrected ('C): 1T
[]samples out of temp criteria. Samples an ice, cooling process
USDA Regulated Soil JeN/A, water sample)
has begun
Did samples Origi a in a quarantine zone within the United Slates: CA, NY, or SC (check maps)?
Yes o
Did samples originate from a foreign source (intern tonally,
including Hawaii and Puerto RICO)? DO [JNc
Comments/DUcre anc :
Chain of Custody Present?
Yes
QN.
❑N/A
1.
Samples Arrived within Hold Time?
Yes
ONO
❑N/A
2.
Short Hold Time Anat sis <72 hr.)?
Yes
[]NO
n A
3.
Rush Turn Around Time Requested?
[]Yes
CfNo
N/A
4.
Sufficient Volume?
9/eses
No
N A
S.
Correct Containers Used?
E-
s-
[IN.
[]NIA
6.
-Pace Containers Used?
SY
-,..Yees
No
N A
Containers Intact?
24-e
NO
N/A
7.
Dissolved analysis: Samples Field Filtered?
❑Yes
❑via
j]n/a
g.
Sample labels Match COC?
es
❑No
❑N/A
9.
1
-Includes Date/Time/ID/Anal sis Matrix: \
Heads ace in VOA Vials (>5-6mm)?
Elyes
[]NO
E N/A
10,
Trip Blank Present?
❑Yes
eallo
❑N/A
11.
Trip Blank Custody Seals Present?
Yes
No
UN/A
COMMENTS/SAMPLE DISCREPANCY
Lot ID of split containers:
CLIENT NOTIFICATION/RESOLUTION
Person contacted:
Project Manager SCURF Review:
Date/Time:
Project Manager SHIP Review:y
Field Date Required? ❑Yes ❑No
Date: Y/
Date: Y/
Page 11 of 13

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Document Name:
Sample Condition Upon Recel t(SCUR)
Document Revised: February 7, 2018
Page 1 of 2
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 #
verified and within the acceptance range for preservation
samples.
Exceptions: VOA, Collform,TOC, Oil and Grease, DRO/8015 (water( DOC, LLHg
"Bottom half of box is to list number of bottle
WO# : 9243297Z
PM: CD1 Due Date: 06/27/19
CLIENT: 92-Goodyear
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Note: whenever there is a discrepancy affecting North Carolina compliance samples, a copy or this torm win to sent to the north C.4ina ocniliii or. Cc,•.•.
Out o1 hold, incorrect presemOve, out of temp, incorrect containers.
Page 12 of 13

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PaceAnalvtical'
CHAIN -OF -CUSTODY / Analytical Request Document
The Chainof-Custody is a LEGAL DOCUMENT. All relevant fields must be completed accurately. p
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Required Client Information: Required Project Intormatier: Invaio, Information: 191 1647
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