NCG030661_MONITORING INFO_20191113

s RIO
STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
DOC TYPE. ❑ HISTORICAL FILE
MONITORING REPORTS
DOC DATE ❑ p!
YYYYMMDD

Stormwater Discharge Monitoring Report
for North Carolina Division of Energy, Mineral and Land Resources General Permit No. NCG030000
Date submitted 10/28/19
CERTIFICATE OF COVERAGE NO. NCG03 0 6 6 1
FACILITY NAME Matlab. Inc. - Plant 16
COUNTY Guilford
PERSON COLLECTING SAMPLES Tait Williams
LABORATORY con -test Lab Cert. # 652
Comments on sample collection or analysis:
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR 2019
SAMPLE PERIOD ❑ Jan -June 0 July -Dec
or ❑ Monthly' (month)
p DDISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
R�>`•� `D flow [:]watersupply ❑SA
❑Othe
N0� 18 `2p19 PLEASE REMEMBER TO SIGN ON PAGES 2 AND/OR 3 4
ow s cT+or+
n No discharge this period?"
Outfall No.
Date Sample
Collected'
(mo/dd/yr)
24-hour rainfall
amount,
Inches3
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
OD400
01119
01051
01094
00552
78141
01
10/16/19
0.51
3.6
6.1
1 0.0080
0
0.055
2.0
N/A
Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfatt.
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.
4 See General Permit, Section 8, 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
_ _ - - - - -- - --- _. - - -- - - ---- - — --- -- - - -- - -- - - g f - - _ -- - - _- -- - -

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."
Press Brower
Name (Print name)
VP of Engineering
Title (Pri
/0 3i l
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 mR/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 No discharge this period?z
- Outfall No.
Date Sample Collected'
(mo/dd/yr)
24-hour rainfall amount,
Inches3
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: 11/1/2018-05/31/2021 SWU-245, last revised 11/1/2018
._ ---- — ---- - -- ----_Yage.2-.of3- _- - ---- -- ---.-

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 DEMUR 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 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:
N 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 afe-signiGcdnt penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
Signature of Permittee
Permit Date:11/1/2018-05/31/2021
/o Jf / 7
Date
SWU-245, last revised 11/1/2018
Page 3 of 3

i
RAIN EVENT DATA
FACILITY: Matlab, Inc. — Plant #16
ADDRESS: 3010 Executive Drive
Greensboro, INC 27206
CONTACT PERSON: Press Bower TELEPHONE: [phone]
STORM EVEN -INFORMATION
DATE
YEAR
MONTH
DAY
19
10
16
HOURS
MINUTES
DURATION
24
0
PRECIP.
AMOUNT (IN.)
.83
RUNOFF
0.083
VOL. M/.GAL.
DAYS
HOURS
PRECEDING
EVENT
3
0
We f
PRINCIPLE EXECUTIVE OFFICER OR AUTHORIZEDAGENTt 2f
L
PRINT
SIGNATURE
DATE
Paul W. Spangenberg
fJ�k I WAVY
1009
10/16/19
43560 x 5 = 261360 x 0.51 = 133293.6 x 0.0833=11103.3 x 7.48 = 83053.1 / 1000000 = 0.83 M/Gal.

STORMWATER DISCHARGE OUTFALL (SDO)
QUALITATIVE MONITORING REPORT
Certification of Coverage No.:
Facility Name:
County:
Permit No: NCG0300661
Matlab, Inc. — Plant #16
Guilford
Expires: 5/31/2021
Greensboro, North Carolina
Inspector Name:
Date of Inspection:
Tait Williams
10/16/19
OUTFALL
DESCRIPTION
Outfall No.:
Structure (pipe, ditch, etc.):
Receiving Stream:
1
Pipe
Buffalo Creek
Describe the industrial activities that occur within the outfall drainage area:
Painting & Coating Manufacturing
Color
Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint (light, medium, dark) as descriptors:
Light tan
Odor
Describe any distinct odors that the discharge may have (i.e. smells strongly of oil, weak chlorine odor, etc.):
None
Clarity
Choose the number which best describes the clarity of the discharge where 1 is clear and 10 is very cloudy (circle one):
1 O 3 4 5 6 7 8 9 10
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 is covered in floating solids (circle one):
O2 3 4 5 6 7 8 9 10
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 (circle one):
O2 3 4 5 6 7 8 9 10
Foam
Is there any foam in the stormwater discharge (circle one)?: Yes N
Oil Sheen
Is there an oil sheen in the stormwater discharge (circle one)?: Yes No
Erosion Deposition
Is there evidence of erosion or deposition at the outfall? (circle one): Yes No
If yes, list and describe:
Other. ,.
Is there other obvious indicators of stormwater pollution in the stormwater discharge (circle one): Yes No
If yes, list and describe:
Rain Event
Was this a Representative Storm Event? X Yes _ No Total Event Precipitation (Inched' 0.51
A measurable storm event is a storm event that results in an actual discharge from the permitted site outfall. The previous measurable storm event
must have been at least 72 hours prior.
' Certification
By this signature I certify that this report is accurate and complete to the best of my knowledge:
Inspector's Signature: /4/E`l4i1raw

STORMWATER FACILITY INSPECTION FORM
Facility Name:
Location:
Certification of Coverage No.:NCG030661
Matlab, Inc. —Plant #16
Greensboro, North Carolina
Expires: 5/31/2021
Number
Inspector's Name:
Date:
Outfalls:
Tait Williams
10/16/19
1of
Con Ing Areas
Evidence of pollutants entering system (circle one): Yes No
If yes, describe:
Areas of potential pollutants entering system:
Describe: None
Control measures present (circle one): Yes No
If yes, describe:
Additional control measures needed (circle one): Yes No
If yes, describe:
Sediment and erosion control measures present (circle one): es No
If yes, describe:
Rip -Rap at discharge and drainages ditches
Describe any new structural slormwater management measures:
None
Potential Pollutant Areas
Describe any loading/unloading operations:
Trucking
Describe any outdoor storage activities:
Wood Pallets, Scrap Metal, Solid waste dumpsters, used equipment
Describe any outdoor manufacturing or processing activities:
None
Describe and dust or particulate generating areas:
None
Describe any onsite waste disposal activities:
None
Significant VAks or Spills
Any reportable spills or leaks in the past year (circle one): Yes No
If yes, date: Impact on stormwater system(s):
Certification
By this signature I certify that this report is accurate and complete to the best of my knowledge:
Inspector's Signature: T1PAl w

Table of Contents
October 28, 2019
Paul Spangenberg
Mid -Atlantic Associates, Inc. - Raleigh, NC
409 Rogers View Court
Raleigh, NC 27610
Project Location: Plant 16- Greensboro, NC
Client Job Number:
Project Number: R2943.10
Laboratory Work Order Number: 19J 1093
Enclosed are results of analyses for samples received by the laboratory on October 16, 2019. If you have any questions
concerning this report, please feel free to contact me.
Sincerely,
ANAA
i
i
Kerry K. McGee
Project Manager
Page 1 of 14

Table of Contents
Table of Contents
Sample Summary
3
Case Narrative
4
Sample Results
5
19J1093-01
5
Sample Preparation Information
i
7
QC Data
8
i
Metals Analyses (Total)
8
B243665
8
Conventional Chemistry Parameters by EPA/APHA/SW-846 Methods (Total)
9
B243511
9
B243535
9
B243937
9
I
Flag/Qualifier Summary
10
Certifications
II
Chain of Custody/Sample Receipt
12
Page 2 of 14

Table of Contents
icon --test
II ANALYTICAL LABORATORY
(. Mid-Atlanlie Associmcs, Inc. - Raleigh, NC
409 Rogers View Court
Rvlcigh, NC 27610
ATTN: Paul Spangenberg
II
I
FAX [phone]' TEL. [phone]
PURCHASE ORDER NUMBER:
PROJECT NUMBER: R2943. 10
A NA LYTI CA L SO M MART
REPORT DATE: 10129/2019
WORK ORDER NUMBER: 19J 1093
The results of analyses performed on the following samples submitted to the CON. TEST Analytical Laboratory are found in this rcpon.
PROJECT' LOCATION: Plant 16- Greensboro, NC
i
FIELD SAMPLE 4 LAB ID: MATRIX SAMPLE DESCRIPTION TEST SUB LAB
I 19JI093-01 Water
EPA 1664B
SM21-222540D
SM21-22 4500 H B
S W-S46 601 OD
Page 3 of 14

Table of Contents
39 Spruce Street' East Longmeadow, MA 01028 *FAX [phone] * TEL. 41
I
CASE: NARRATIVE SUMMARY
I I
All reported results are within defined laboratory quality control objectives unless listed below or otherwise qualified in this report.
SM21-224500 H B
Qualifications:
R-05
Holding time was exceeded. pH analysis should he performed immediately at time of sampling. Nominal 15 minute holding time was
exceeded.
Aru lyte & Samplopd Qualified:
�pll
19J 1093-0111 ]. B24351 I -DUP I
The results ofanalyses reported only relate to samples submitted to the Con -Test Analytical Laboratory for testing.
I certify that the analyses listed above, unless specifically listed as subcontracted, irony, were performed under my direction according to the approved methodologies listed
in this document, and that based upon my inquiry of those individuals immediately responsible for obtaining the information, the material contained in this report is, to the
best of my knowledge and belief, accurate and complete.
r-ti
Y
Tod li. Kopyscinski
at Laborory Director
Page 4 of 14

Table of Contents
con -test
ANALYTICAL LABORATORY
39 Spruce Street' East Longmeadow, MA 01026FAX [phone]' TEL. [phone]
]'reject Locution: Plant 16- Greensboro, NC Sample Description: Work Ordcr. 19J1093
Date Received: 1011612019
Field Sample #: I Sampled: 10/16/2019 11:00
Sample ID: 19J1093-01
Sample Matrix: Water
Metals Analyses (1'o1n1)
Dale
DateR ime
Anulyle
Results
RI,
DL
Units Dilution Flog/Qual
Methad
Prepared
Analyzed
Analyst
� Copper
O,OO80
0.010
0.0068
mg/L I 3
SW-8466010D
10/19/19
101211191923
Mill
Lead
ND
0.010
0.0060
mg/L I
SW-84660101)
10/19/19
10/21/1919:23
mill
Zinc
0,055
0.010
0,0051
mg/L I
SW-8466010D
10/19/19
1021/1919:23
Milt
Page 5 of 14

I
I
Table of Contents
con -test°
ANALYTICAL LABORATORY
I _ I
II 39 Spruce Street' East Longmeadow, MA01028FAX [phone]' TEL. [phone]
Project Location: Plant 16.Greensboro, NC Sample Description: Work Order: 19J 1093
Date Received: 10f16/2019
Field Sample #: I Sampled: 10/I6/2019 11:00
Sample ID: 19J 1093-01
Samnle Matrix: Water
Conventional Chemistry Parameters hp F;PA/APII,VSII IU6 Methods LTotal)
Date Dien ime
Anal)1c Results RI, DL Units Dilution FlaglQual Method Prepared Aaolyzed Analyst
pH0184-C 6.1 pH Units 1 H-05 SM21-22 45M 11 It 10/17/19 10/17/1921:02 AIA
Total Suspended Solids 3.6 2.0 0.82 mg/1- 1 SM21-222540D 10/18/19 10/19/1913:20 LI.
Oil &Grease (116M) 2.0 2.S 2.0 MP/I. I 1 HPA I664D 10123/19 I0123/1913:00 LL
Page 6 of 14

I
Table of Contents
Ocon-tesV
ANALYTICAL LABORATORY
i
39 Spruce StreetEast Longmeadow, MA 01028' FAX [phone]' TEL. [phone] t
Sample Extraction Data
EPA 16648
i
1 Lab Number lF'icld lD Batch Initia11m1,1 Datc
•19J 1093-0111] B243937 500 10/23/19
!SP121-22 2540D
Lab Numhcr IFicld IDl
Balch
Initial lmLl
Dmc
11911093-01 [11
B243535
250
10/18/19
'SM21-22 4500 II B
I
Lab Numhcr IFicld [DI
Balch
Initial ImLI
Dotc
�19J1093-01 III
B243511
50.0
10/17/19
i
Prep Method: SN'-846 3005A-SN'-846 6010D
�I.ab Numhcr IFicld ID]
Batch
Initial m Ll Final lmLl
Dmc
19JI093-01 [11
B243665
50.0 500
10/19/19
Page 7 of 14

Table of Contents
com test/
ANALYTICAL LABORATORY
39 Spruce Street' East Longmeadow, MA 01028FAX [phone]' TEL. [phone]
QUALITYCONTROL
Metals Analyses (Total) - Quality Control
i
Reporting Spike Source %REC ,RPD
Analyze Result Limit Units Level Result %REC Limits RPD Limit Notes
Batch R243665 - SN'-846 3005A
Blank(0243665-BLK 1)
Prepared: 10119/19 Analyzed: 10/21/19
'
Copper
ND
0.010
mglL
Lcod
ND
0,010
yawl,
Zinc
ND
0.010
mg/L
LCS (11243665-IISI)
Prepared: 10/19/19 Analyzed: 10/21/19
'Copper
0.978
0.010
mWL
1.00 97.8
80-120
Lead
i
0.548
0.010
mg/L
0.500 110
80.120
iZae
1.08
0,010
me/I,
1.00 108
80-120
LCS Dup (R243665-RSDI)
Prepared: 10/19/19 Analyzed: 10/21/19
COpper
0.961
0010
mg/L
1.00 96.1
80-120
1.72
20
I Lead
0.540
0.010
mg/L
0,500 108
80-120
1.57
20
Zinc
fII
L07
0.010
mg/L
1.00 107
80.120
0677
20
77-1
Page 8 of 14
I

Table of Contents
conetest°'
I
ANALYTICAL LABORATORY
39 Spruce StreetEast Longmeadow, MA 01028' FAX [phone]' TEL. [phone]
QUALITY CONTROL i
Com entionul Chemistry Parameters by FPA/APIIA/S\Y-846 Methods (Total) - Qnalh Control
Reporting Spike Soorec %REC RPD
Analyte Result Limit Units Level Resull %REC Limits RPD Limit Notes
Balch B243511 - SM21-22 4500 11 R
10/17/19
!PH 6.02 pH Units 6M 100 90-110
I
Duplicate(8243511-DUPI) Source: 19J1093-01 Prepared&Analyzed: 10/17/19
pit 61 pit Umts 6.1 0,131 5 H-05
,Batch B243535 - SM21-22 2540D
Blank (B243535-RLKI) Prepared & Analyzed: 10/18/19
'Total Suspended Solids ND 2.5 mg1l,
LCS (B243535-US n Prepared & Analyzed: 10/18/19
,Total Suspended Solids 200 20 mg/L 200 100 57.6-118
Batch B243937 - FPA 1664B
Blank (B243937-BLKI)
Prepared & Analyzed: 10/23/19
Oil & Grease (HEM)
NO L4 mg/L
Blank (11243937-11LK2)
Prepared & Analyzed: 10/23/19
Oil & Grease (HEM)
'LCS
ND 28 mg/L
(8243937-BSl)
Prepared & Analyzed: 10/23/19
Oil & Grease (HEM)
11
20 eng/L
20.0 102 78-114
LCS (11243937-BS2)
Prepared & Analyzed: 10/23/19
Oil & Grease (IIIiM) 340 mg/L 400 84.5 78-114
NI RI. Cheek (8243937 -MRI,1) Prepared & Analyzed: 10/23/19
Oil & Grease (IIIiM) 1.60 1.4 mg/L 1.40 114 0-200
Page 9 of 14

Table of Contents
39 Spruce Street' East Longmeadow, MA 01028' FAX [phone]' TEL. [phone]
FEAC/QUAI.IPIER SUMMARY
• QC result is outside of established limits,
f Wide recovery limits established for difficult compound.
j Wide RPD limits established for difficult compound.
N Dam exceeded client recommended or regulatory level
ND Not Detected
RI, Rcponing Limit is at the level ofyuantitation (LOQ)
DI, Detection Limit is the lower limit ofdetcetinn determined by the MDI, study
MCI. Maximum Contaminant Level
Percent recoveries and relative percent differences (RPDs) arc determined by the software using values in the
calculation which have not been rounded.
No results have been blank subtracted unless specified in the case narrative section.
I1-05 Holding time was exceeded. pli analysis should be performed immediately at time of sampling. Nominal 15
minute bolding time was exceeded.
J Detected but below the Reporting Limit (lowest calibration standard); therefore, result is an estimated
concentration (CLP 1-Flag).
Page 10 of 14

Table of Contents
SV
TORY
I.OngmeartOW, MHUIU[e-FHA41JJ04D-n4U1 -ILL. 91SISLS-LJ3L
CERTIFICATIONS
Cerlifted Analyses included in this Report
Certifications
LAnulytc
EPA 1664Ein Ilurer
Oil & Grc.sc (HEM) CTMA,NH,NY,RLNC,ME,VA
S'A121-22 2540D in ;fate,
Total Suspended Solids CTMA,NH,NY,RLNC,ME,VA
SA121-22 450011 B in Rarer
I
PH CTMA,RI
Sll'-846 60101) in IlWer
Copper CT,NH,NY,MI VA \C
Lead CT,NH,NY,MF,VA,NC
Zinc CT,NH,NY,ME,VA,NC
The CON -TEST Environmental Laboratory operates under the following certifications and accreditations:
Code Description
Number
Expires
AlHA AIHA-LAP, LLC- ISO 17025:2017
100033
03/1/2020
MA Massachusetts DEP
M-MA100
06/30/2020
CT Connecticut Department of Pobli a Health
PH-0567
09/302021
NY New York State Department of Health
10899 NELAP
04/l/2020
NH-S New Hampshire Environmental Lab
2516 NELAP
02/5/2020
RI Rhode Island Department of Health
LAOOOI 12
12/302019
NC North Carolina Div. of Water Quality
652
12/31/2019
NJ New Jersey DEP
MA007 NELAP
06/30/2020
I. PI- Florida Depanment of Health
E871027 NELAP
06/30/2020
V'IVermont Department of Health Lead Laboratory
L1.015036
07/302020
ME State of Maine
2011028
06/9/2021
VA Commonwealth of Virginia
460217
12/14/2019
NII-P New Hampshire Environmental Lab
2557 NELAP
09/6/2020
V'I'-DW Vermont Department oflicalth Drinking Water
I
V9=255716
06/12/2020
NC-DW North Carolina Department of Health
I
25703
07/312020
PA Commonwealth of Pennsylvania DEP
68-05812
06/30/2020
Page 11 of 14

htto://www.contestlaDs.com
Doc p 379 Rev 103242017
jL,���IjI�III1 {,
'XIII" con-tEst'
Phone: [phone]
CHAIN OF CUSTODY RECORD (loft Carotlnal
39 Spruce Street Page _7_ of _7_
Fast Longmeadow, MA 01028
Fax: A7.6 3-525405
Ema0: Infomcomestlabs.com
7-Day ❑
t0-Day
a
1 2 1 7 1 t
a of Containers
Mid Atlant7c Assotlates
Due Dace:
H IN IN N I
I I' Preservatlon Code
Address: 409 Rogers Vies
P
G
P
P
P
P
Is
Container Code
Phone: [phone],0630
1 Day
2-Day
❑ 1•Day
❑ 4-Day
❑
❑
ANALYSIS
REQUESTED
❑• Field Filtered
MaIWI Inc.
Project Location:
Plant 16 - Greensboro, NC
t
�
O
�
u'
a
❑ tab to Filter _
-..• _
Format: PDF Ej EXCEL ❑
Other:
CLP Like Data Pkg Required:
Email To: p5)ar0enber00D18a00jIO0.CQrn
Project Number-. R2943.10
Project Winger: Paul W. Spangenberg
• ,
❑ r new Filtered
❑ -lab to Fiitec -
Con -Test Quote Name/N
Im ice Recident: DSDa00enberOCOlmeaOnline.Wm
Relinquished try: (signature]
Tact W(Acameoru
by. islgnaturel
N
O
A
j 10/16/19, tl:00
1 10116119, I1:00
j 10116119, I1:00
0
10/16/19, 11:00
10/16/19, 11:00
10116119, WOO
Gmemmem
Federal
250.9950
I Matrix, Codes:
y -eCaee
_1a
GW-Ground Watef ...; .
:WW=Waste Water
O
L
X
X
DW- Drinking Watery-'
'A a Air
O
L
X
'.S - Soil -.. ,....;_ ..
O
L
X
x
X
'SOL=Solid '
O - Other (Please-
def6le)
t Preservation Codes:'.'
:I - ked
H-HCL
:M -methanol
S - Sulfuric Acid
B - Sodium Bisulfate
X - Sodium Hydroxide '
T - Sodium
Thiosulfate
0- Other (please.
Please use the follovdrig codes to indicate possible sample concentration within the
define)
Conc Code column above:
H - High; M - Mei lum; L - Low; C - Clean; U - Unknown
'Container Coded:'' "
A - Amber Gtas
G - Glass
Program Information
DSCA ❑ UST/Trust Fund
P - Plastic
ST - Sterile
SWS Landfill ElREC
V - Vial
71 IHSB Orphaned Landfill
3 - Summ , Canister".
State Lead
T - Tedlar Bag
Other!
O - Other (please-,. -
define)
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477255547521�
Delivered
Thursday 10/17/2019 at 9.04 am
FROM
Raleigh, NC US
Shipment Facts
TRACKING NUMBER
477255547521
DIMENSIONS
18x1501 in.
p.
TOTAL SHIPMENT WEIGHT
15lbs / 6.8 kgs
DELIVERED
Signed for by: RRETRAITIS
GET STATUS UPDATES
OBTAIN PROOF OF DELIVERY
SERVICE
FedEx Priority Overnight
DELIVERED TO
Receptionist/Front Desk
TERMS
Third Party
i, SPECIAL HANDLING SECTION STANDARD TRANSIT
Deliver Weekday, Additional Handling 0
Surcharge 10/17/2019 by 10:30 am
ACTUAL DELIVERY
Thu 10/17/2019 9:04 am
Travel History
TO
East Longmeadow, MA US
WEIGHT
15 Ibs / 6.8 kgs
TOTAL PIECES
1
Thursday, 10/17/2019 .. .. o,.. ,.. ... .
9:04 am East Longmeadow, MA Delivered
873 am WINDSOR LOCKS, CT On FedEx vehicle for delivery
7:20 am WINDSOR LOCKS, CT At local FedEx facility
Table of Contents
y O
Local Scan Time u
Page 13 of 14

Table of Contents
I Have Not Confirmed Sample Container
Numbers With Lab Staff Before Relinquishing
Over Samples
Login Sample Receipt Checklist - (Rejection Criteria Listing - Using Acceptance Policy) Any False
rT
State ent will be rought to the attention of the Client - State True or False
St
Client , `% bi V1(1h L
Received By Date Ir) ° Time 61
How were the samples In Cooler T No Cooler On ice I No Ice
received? Direct from Sampling Ambient Melted Ice
Were samples within
By Gun # 5,- Actual Temp - 1-{. 2-
Temperature? 2-6°C -f By Blank # Actual Temp-
Was Custody Seal Intact? Were Samples Tampered with?
Was COC Relinquished ? _� Does Chain Agree With Samples? t-
Are there broken/leaking/loose caps on any samples?
Is CDC in ink/ Legible? j Were samples received within holding time?
Did COC include all Client T Analysis T Sampler Name 7-
pertinent Information? Project T
Are Sample labels filled out and legible? G
Are there Lab to Filters?
Are there Rushes?
Are there Short Holds? 7-
is there enough Volume? f-
Is there Headspace where applicable?
(Proper Media/Containers Used? T
'Were trip blanks received?
i Do all samples have the proper pH?
ID's — Collection Dates/Times
Who was notified?
Who was notified?
Who was notified? u
MS/MSD?_f—_
Is splitting samples required? f
On COC? F
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Page 14 of 14