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Home My WebLink AboutNCG030513_MONITORING INFO_20200107/Vl -lz/o STORMWATER DIVISION CODING SHEET NCG PERMITS PERMIT NO. IV L& (}-3U51 3 DOC TYPE ❑ HISTORICAL FILE (Y MONITORING REPORTS DOC DATE ❑ a �`o -7 YYYYM M DD DOC TYPE 1 ❑ HISTORICAL FILE ❑ MONITORING REPORTS DOC DATE ❑ YYYYM M DD (D0D,rrZ'?ZZAM The Goodyear Tire & Rubber Company — Statesville Mold Plant 108 Business ark Drive Statesville, NC 28677 January 2, 2020 Division of Water Quality Attn: DWQ Central Piles 1617 Mail Service Center Raleigh, NC 27699-1617 RE: Storm Water DMR, General Permit NCG030000, COG NCG030513 Dear Mr. or Ms., The Goodyear "fire & 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 December 10, 2019 from outfall 41. If further information is required, please do not hesitate to contact me at 704-928-4505. Sincerely. lt4-c2e Nicholas Pugitl G Quality Manager The Goodyear "fire & Rubber Company RFCFiVED JAN 0 7 20N Certified Mail No. 7014 2120 0000 7370 5825 :1='d IL"I• FILC") Return Receipt Requested DbVR SECT1O;1 Attachment cc: file Stormwater Discharge Monitoring Report for North Carolina Division of Energy, Mineral and Land Resources General Permit No. NCG030000 Date submitted 7/9/2019 CERTIFICATE OF COVERAGE NO. NCG03 0 5 1 3 FACILITYNAME Goodyear Tire& Rubber Co -Statesville COUNTY Iredell PERSON COLLECTING SAMPLES Nicholas Fugitt LABORATORY Pace Analytical Services LLC Lab Cert. # 12 Comments on sample collection or analysis: Part A: Stormwater Benchmarks and Monitoring Results SAMPLE COLLECTION YEAR 201Y SAMPLE PERIOD ❑ Jan -June Q July -Dec or El Monthly' (month) DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA ❑Zero -flow ❑Water Supply [_]SA *Other Class C PLEASE REMEMBER TO SIGN ON PAGES 2 AND/OR 3 4 ❑ No discharge this period?2 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/L' 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 Outfall 1 Pond 12/10 0.4 in 11.7 mg/L 7.02 <0.005 mg/L <0.005 mg/L 0.020 mg/L <5.0 mg/L NA ' Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outtall. z For sampling periods with no discharge at any single outtall, 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." Joe Wegmiller Name (Print name) Manufacturing Director Title (Print title) J, W J� , t Z Zazo 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. ] No discharge this period?2 Outfall No. Date Sample Collected' (mo/dd/yr) 24-hour rainfall amount, Inches' New Motor Oil or Hydraulic Oil Usage Non -Polar 0&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: 11/1/2018-05/31/2021 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 ANY ONE OUTFALL? YES ❑ NO Q IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Mail an original copy of this DMR including all "No Discharge" 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. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations." SiJ00— f 11z zo 0 D to Permit Date: 11/1/2018-05/31/2021 SWU-245, last revised 11/1/2018 Page 3 of 3 ace Analytical wm .pacelabe.00m December 24, 2019 Nicholas Fugitt Goodyear 108 Business Park Drive Statesville, NC 28677 RE: Project: Stormwater Sample Pace Project No.: 92456863 Dear Nicholas Fugitt: Pace Analytical Services, LLC 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)878-9092 Enclosed are the analytical results for sample(s) received by the laboratory on December 11, 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 christopher.derouen@pacelabs.com (828)254-7176 Project Manager Enclosures �Q:PCCRp�'l, '4BpEptO' 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 12 aceAnalytical www.pacalehs.cam CERTIFICATIONS Project: Stormwater Sample Pace Project No.: 92456863 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 If 5342 VirginiaNELAP Certification #: 460221 North Carolina Wastewater Certification #: 12 Pace Analytical Services Asheville 2225 Riverside Drive, Asheville, NC 28804 Florida/NELAP Certification #: E87648 Massachusetts Certification #: M-NC030 North Carolina Drinking Water Certification #: 37712 North Carolina Wastewater Certification #: 40 South Carolina Certification #: 99030001 VirginiaNELAP Certification #: 460222 REPORT OF LABORATORY ANALYSIS Pace Analytical Services, LLC 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 This report shall not be reproduced, except in full, without the written consent of Pace Analytical Services, LLC. Page 2 of 12 aceAnalytical www.pacelabs.en, SAMPLE ANALYTE COUNT Pace Analytical Services, LLC 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 - Project: Pace Project No.: Stormwater Sample 92456863 I I Analytes Lab ID Sample ID Method Analysts Reported Laboratory �92456863001 Stormwatcr Samples EPA1664B HH 1 PASI-C EPA 1664B HH 1 PASI-C EPA 200.7 Rev 4.41994 SH7 3 PASI-A SM 2540D-2011 CJL 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 12 aceAnalytical e www.pacelahsxom ANALYTICAL RESULTS Pace Analytical Services, LLC 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 Project: Stormwater Sample Pace Project No.: 92456863 Sample: Stormwater Samples Lab ID: 92456863001 Collected: 12/10/19 16:45 Received: 12/11/19 09:43 Matrix: Water Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Oual 1 HEM, Oil and Grease Analytical Method: EPA 1664B Oil and Grease ND mg/L 5.0 1 12/24/19 07:09 Mt 1664 SGT-HEM, TPH Analytical Method: EPA 1664B Total Petroleum Hydrocarbons ND mg/L 5.0 1 12/24/1907:09 Ml 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 12/19/19 01:06 12/19/19 09:41 7440-50-8 Lead ND ug/L 5.0 1 12/19/19 01:06 12/19/19 09:41 7439-92-1 Zinc 20.0 ug/L 10.0 1 12119/1901:06 12/19/1909:41 7440-66-6 2540D Total Suspended Solids Analytical Method: SM 2540D-2011 Total Suspended Solids 11.7 mg/L 8.3 1 12/15/1912:16 REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Dale: 12/24/2019 04:15 PM without the written consent of Pace Analytical Services, LLC Page 4 of 12 (�IaceAnalytical' www.pacelatexom QUALITY CONTROL DATA Project: Stormwater Sample Pace Project No.: 92456863 OC Batch: 516527 Analysis Method: EPA 1664E QC Batch Method: EPA 1664B Analysis Description: 1664 HEM, Oil and Grease Associated Lab Samples: 92456863001 METHOD BLANK: 2767434 Associated Lab Samples: 92456863001 Parameter Units Oil and Grease mg/L Matrix: Water Blank Reporting Result Limit Analyzed Qualifiers ND 5.0 12/24/1907:09 LABORATORY CONTROL SAMPLE: 2767435 Spike LCS LCS Parameter Units Conc. Result a/ Rec Oil and Grease mg/L 40 36.3 91 n MATRIX SPIKE SAMPLE: 2767436 92456863001 Spike MS Parameter Units Result Conc. Result Oil and Grease mg/L ND 40 14.1 Pace Analytical Services, LLC 9800 Kincey Ave. Suite 100 Huntersville, NC 2807E (704)875-9092 % Rec Limits Qualifiers 78-114 MS % Rec % Rec Limits Qualifiers 30 78-114 M1 Results presented on this page are in the units Indicated by the "Units" redhead except where an alternate unit is presented to the right or the result. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 12/24/2019 04:15 PM without the written consent of Pace Analytical Services, LLC. Page 5 of 12 aceAnalytical www.pacelaba,cont QUALITY CONTROL DATA Project: Stormwater Sample Pace Project No.: 92456863 QC Batch: 516529 Analysis Method: EPA 1664E QC Batch Method: EPA 1664B Analysis Description: 1664 SGT-HEM, TPH Associated Lab Samples: 92456863001 METHOD BLANK: 2767443 Matrix: Water Associated Lab Samples: 92456863001 Blank Reporting Parameter Units Result Limit Analyzed Qualifiers Total Petroleum Hydrocarbons mg/L ND 5.0 12/24/19 07:09 LABORATORY CONTROL SAMPLE: 2767444. Parameter Units Total Petroleum Hydrocarbons mg/L MATRIX SPIKE SAMPLE: 2767445 Parameter Units Total Petroleum Hydrocarbons mg/L Pace Analytical Services, LLC 9800 Kincey Ave. Suite 100 Huntersville, NC 20078 (704)875-9092 Spike LCS LCS %Rec Conc. Result % Rec Limits Qualifiers 20 20.9 104 64-132 92456863001 Spike MS MS % Rec Result Conc. Result e/ Rec Limits Qualifiers ND 20 5.4 17 64-132 M1 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, Dale: 12/24/2019 04:15 PM without the written consent of Pace Analytical Services, L-C. Page 6 of 12 ace Analytical www.pacelahs.com QUALITY CONTROL DATA Project: Stormwater Sample Pace Project No.: 92456863 QC Batch: 515669 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: 92456863001 METHOD BLANK: 2763216 Matrix: Water Associated Lab Samples: 92456863001 Blank Reporting Parameter Units Result Limit Analyzed Qualifiers Copper ug/L ND 5.0 12/1911909:18 Lead ug/L ND 5.0 12/1911909:18 Zinc ug/L ND 10.0 12/19/1909:18 Pace Analytical Services, LLC 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 LABORATORY CONTROL SAMPLE: 2763217 Spike LCS LCS % Rec Parameter Units Cone. Result e/ Rec Limits Qualifiers Copper ug/L 500 482 96 85-115 Lead ug/L 500 500 100 85-115 Zinc ug/L 500 493 99 85-115 MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2763218 MS 92456956001 Spike Parameter Units Result Cone. Copper ug/L 5.2 500 Lead uglL ND 500 Zinc uglL 2.4 500 mg/L MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2763220 MS 92456984001 Spike Parameter Units Result Conc. Copper ug/L 73.6 500 Lead ug/L <1.6 500 Zinc ug/L 638 500 2763219 MSD Spike MS MSD MS MSD % Rec Cone. Result Result % Rec e/ Rec Limits RPD 500 532 528 105 104 70-130 1 500 493 486 98 97 70-130 1 500 2960 2900 116 104 70-130 2 2763221 MSD Spike MS MSD MS MSD % Rec Conc. Result Result %Rec %Rec Limits RPD 500 592 584 104 102 70-130 1 500 523 514 104 103 70-130 2 500 1160 1150 104 102 70-130 1 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: 12/24/2019 04:15 PM without the written cansent of Pace Analytical Services, LLC, Qual Qual Page 7 of 12 laceAnalyticale wwei.pacelabs.cem Project: Stormwater Sample Pace Project No.: 92456863 OC Batch: 514898 QC Batch Method: SM 2540D-2011 Associated Lab Samples: 92456863001 METHOD BLANK: 2759614 Associated Lab Samples: 92456863001 Parameter Units Total Suspended Solids mg/L LABORATORY CONTROL SAMPLE: 2759615 Parameter Units Total Suspended Solids mg/L Pace Analytical Services, LLC 9800 Kinney Ave. Suite 100 Huntersville, NC 2BD78 (704)875-9092 QUALITY CONTROL DATA Analysis Method: SM 254OD-2011 Analysis Description: 2540D Total Suspended Solids Matrix: Water Blank Reporting Result Limit Analyzed Qualifiers ND 2.5 12/15/1912:12 Spike LCS LCS %Rec Conc. Result % Rec Limits Qualifiers 250 244 98 90-110 SAMPLE DUPLICATE: 2759616 92456857001 Dup Parameter Units Result Result RPD Qualifiers Total Suspended Solids mg/L 39.2 44.0 12 SAMPLE DUPLICATE: 2759617 92456860002 Dup Parameter Units Result Result RPD Qualifiers Total Suspended Solids mg/L 34.5 38.0 10 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: 12/24/2019 04:15 PM without the written consent of Pace Analytical Services, L-C. Page 8 of 12 ace Analytical www.pacelaba.com QUALIFIERS Project: Stormwater Sample Pace Project No.: 92456863 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 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 PQL - Practical Quantitalion 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, unfounded 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 PASI-A Pace Analytical Services -Asheville PASI-C Pace Analytical Services - Charlotte ANALYTE QUALIFIERS Ml Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS) recovery. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 12/24/2019 04:15 PM without the written consent of Pace Analytical Services, LLC. Page 9 of 12 aceAnalytical w"..pacelahs.com QUALITY CONTROL DATA CROSS REFERENCE TABLE Pace Analytical Services, LLC 9800 Kincey Ave. Suite 100 Hunlersville, NC 28078 (704)875-9092 Project: Pace Project No.: Stormwater Sample 92456863 Analytical Lab ID Sample ID QC Batch Method QC Batch Analytical Method Batch 92456863001 Stormwater Samples EPA 1664E 516527 92456863001 Stormwater Samples EPA 1664B 516529 92456863001 Stormwater Samples EPA 200.7 Rev 4.4 1994 515669 EPA 200.7 Rev 4.4 1994 515690 92456863001 Stormwater Samples SM 2540D-2011 514898 REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 12/24/2019 04:15 PM without the written consent of Pace Analytical Services, -LC. Page 10 of 12 WOC Analytical Request Document LAB USE ONLY- Affix Workordi CHAIN -OF -CUSTODY 0 II'll'I'II PaceAnalytical- IIIII I'll'II Chain-of-Custody is a LEGAL DOCUMENT Complete all relevent fields 82456863 d Ca _ as /i ALL SHADED nc. _ _ C_ Company: Billing Information: Contamerpreservative T e ILab Project Manager: - Address: Report Email TO: "Preservative TVPesa])nitricacid, l2l sulfuric acid, 131had acid.ascorbic aci.(B)tu ianoniu \ 1 _ I (.1\CJ I45 QJ Gl, 'rl( r I .'Y ` l+'�iC IG) metM1anoL IJ) aotliunt biwllatq 18l radium thiomlfatq (9)hchauic 19l henanC. suffatc. (A) ascorbic acid. IB) ammonium sulfate. hydroxide TSP, W) Unpresc,cd.]O) Other Copy To: Site Collection Info/Addr ^� (C) ammonium ID) iJ Analyses Lab Profile/Line: Customer Project Name/Nu\\m.. bee State: County/City: Time Zone Collected: nab Sample Receipe Checklist: L - '}'E Ui=ilc `G\,v'�V E C � %• 4,s,. PT MT C( ET i• Custody Seals Present/Intact Y N� Custody Signatures Present }' Ir Collector SignaturC Present t [: ��r Phone: Cc10 (tg��g[ J V O /S Site/Farili[ ID A: �OO Compliance Monitoring? Email: l Ves I )NO Bottles Incacc N NA Correct Bottles N NA succor irnc v^iume IVIN NA Collected By (print). .., Purchase Order It DW PWS ID B: R Quote B: DW Location Code: Samp'_us Received on Ice N? vow - naadupace wemtpcable x N USDA Regulated Soils Y N(?c� Cron trd By ]siC^•azuret)-�: Tw^around Date Recui^.•d: rI�mmetlia[c•Iy Parke on Ice: ] NO Samples in Ilolding 'Time (t'�N Residual chlorine Present N 19.Zr S ple Disposal: Rush: Field Filtered (" applicable): 11 up..0 xf approVrisu ] ] Return ( ] Same Day I I Next Day ( j Yes No '�( ✓ Cl Scrips: Sample pll Acceptable 1' ❑ NA )Archive: ] ] Z Day I 13 Day I ] 4 Day I ISDay Analysis: p0 strips: I Hold: Expedite fhaBes Apply) .Z Sulfide present Y N dA Lead ACCtate strips: ' Matrix Codes (Insert in Matrix box below): Drinking Water (DW), Ground Water (GW), Wastewater (WW), Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue ITS), Bioassay (B), Vapor (V), Other (OT) LAB USE ONLY: Lab Sample x i Comments: Comp/ Collected (or Res 11 of Customer Sample ID Matrix Grab Composite Start) Composite End CI Ctns 1 _T Date IIme Date Time Z �5 tj 4s Cushn^cr Remarks /Special Conditions/ Possible Hazards: Type of Ice Used: Wet Blue Dry None SHORT HOLDS PRESENT(<7 hours): Y N N/A Lab Sample Temperature l ofo : Temp Blank Re eived: T NA Therm I Packing Material Use r Lab TrackinD rt, � 24 15529 UponfL Cooler 1 Temp Upon Recemt aC Temp r: Cooler 1 Therm Carr. Factor ftadchem samples) screened (<$BD rpm): Y1./N NA Samples received via: FEDEX UPS lien[ Courier Pace Courier Cooler l Corrected Temp: (r. oC Comments: Relingaiyted by/Company: (Signal u ) ^ Date/Tlme: Receivo'Q�Iy/Company: s ature) Date/Ti oe: MTJL LAB USE ONLY Table it: `j .y f - .... Acctnnu: f ( i RCiin ished by/Company: (Signature) . Data/Time: Reeved by/ ompany: (Signature) Date/Timc: Template: Trip Blank Received: Y N NA Prelogin: HCL McOH TSP Cher Relinquished by/Company:(Signature) Dale/Time: Received by/Company:(Signature) Date/Tin'e: PM: Non Conform e(z): Page: PB: YES / rN0 of: