NCG060020_MONITORING INFO_20190821

w S"
STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NC b 0 a0
DOC TYPE
❑ HISTORICAL FILE
MONITORING REPORTS
DOC DATE
❑ % �,
YYYYM M D D

T
Tyson
August 12, 2019
North Carolina Department of Environment, Health and Natural Resources
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: General Permit No. NCG060000y�i��D
Tyson Farms, Inc. - Wilkesboro Co I x�
COC NCG060020 AUG 21 2019
Wilkes County
CENTRAL FILES
Dear Madam or Sir: DWR SECTION
AUG 2
CE�Nrt- 1,
DVMSccrlCFs
Enclosed are two copies of the required storm water sampling results.
For the outfalls Covered under the above subject permit and certificate of coverage.
Tyson Farms, Inc. Storm water sampling Period I semi-annual monitoring. Data receive for PRISM labs
indicated Wilk —03 fecal parameters was above the benchmark.
At the request of the Winston Salem office third sampling point was added to this report.
Tyson Foods, Inc. has made significant improvements to reduce the concentrations of the parameter of
concern.
Please contact me at 336- 651- 3836 should you have any questions.
S' rely,
JaJa es Brown
Complex Environment Manager
Tyson Farms Inc. Fresh Retail Division 704 Factory Wilkesboro, N.C. 28697
336-651-3836 336.838.2171 Fax:33.65r.3867 w Aysonfoods.00m

SEMI-ANNUAL STORMWATER DISCHARGE MONITORING REPORT
For North Carolina Division of Water Quality General Permit No. NCG060000
Date submitted: Aueust 12. 2019
CERTIFICATE OF COVERAGE NO. NCG060020 SAMPLE COLLECTION YEAR 2019
FACILITY NAME Tyson Farms Inc. FACILITY ACTIVITIES INCLUDE (check all that apply):
Wilkesboro Complex ® use/process meats ❑ use animal fats/byproducts
COUNTY Wilkes DISCHARGING TO SALTWATERS? OYES ®NO
PERSON COLLECTING SAMPLES lames Brown
LABORATORY Prism Labs Lab Cert. it 402
Part A: Storm water Benchmarks and Monitoring Results
PLEASE REMEMBER TO SIGN ON THE REVERSE 4
Total event rainfall Z 0.32 or ❑ No discharge this period'
Outfall No.
Sample Collected,
Mo./dd./yr.
TSS,
mg/L
pH,
Standard units
COD,
mg/L
Oil and Grease,
mg/L
Fecal Coliform',
Colonies per 100 ml
Enterococci',
Colonies per 100 ml
Benchmark
-
100 or 504
Within 6.0 — 9.0
120
30
1000
500
WILK-01
07/22/2019
16
7AS
110
5.0
2
NA
WILK-02
07/22/2019
13
6.94
78
5.2
4
NA
WILK-03
07/22/2019
46
6.85
65
5.0
2800
NA
1 Only applies to facilities that use/process meats.
2The total precipitation must be recorded using data from an on -site rain gauge.
3 For sampling periods with no discharge at any outfalls. You must still submit this discharge monitoring report with a checkmark here.
'See General Permit text,Table 3 identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ® Yes ❑ no
Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new motor oil/month.
(ifves, complete Part B)
Outfall No.
Sample Collected,
Mo./dd./yr.
Oil and Grease,
mg/L
Non Polar Oil &
Grease/TPH
mg/L
TSS,
mg/L
pH,
Standard units
New Motor Oil Usage,
Annual average gal/mo
Benchmark
-
30
15
100or504
6.0-9.0
-
WILK - 01
07/22/2019
-5.0
5.0
16
7.15
630
1 Only applies to facilities that use/process meats.
' The total precipitation must be recorded using data from an on -site rain gauge.
3 For sampling periods with no discharge at any outfalls, you must still submit this discharge monitoring report with a checkmark here.
4See General Permit text table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
SWU-249 Last Revised: October 18, 2012
Page I of 2

*FOR PART A AND PART B MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1REQUIREMENTS. 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
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an original and one copy of this DMR including all "No Discharge" reports within 30 days of receipt of the lob 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, NC 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."
of Permittee)
,�g-ly
- �9
(Date)
Additional copies of this form may be downloaded at: http://portal.ncdenr.org/web/wq/ws/su/npdessw#tab-4
S W U-249
Last Revised: October 18, 2012
Page 2 of 2

e
PF IPP
��� ice,
NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this form, please visit: httl27//portal.ncdenr.org/­web/wq/ws/su/­npdessw#tab-4'
Permit No: N/C/G/0/6/0/0/0/0 or Certificate of Coverage No. N/C/G/0/6/0/0/2/0
Facility Name: Tyson Farms Inc
County: Wilkes
Phone No: 336.838.2171
Inspector: James Brown
Date of Inspection: 07/22/2019
Time of Inspection: (p'.15 ,P tvm
Total Event Precipitation (inches): 0.32
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
U Yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureablestorm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be performed during
•' representative storm event" or during a "measureable storm event" However, some permits do not have this
requirement. Please refer to these definitions, if applicable.
A "representative storm event" is a storm event that measures greater than 0.1 inches of rainfall and that is preceded
by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
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. The 72-hour storm interval does not apply if the permittee is able to document that a shorter interval is
representative for local storm events during the sampling period, and the permittee obtains approval from the local DWQ
Regional Office.
By this s n,`ature, I certify that this report is accurate and complete to the best of my knowledge:
Permittee or Designee)
Pagel of 2
SW U-242, Last modified 10/25/2012

1. Outfall Description:\ D
Outfall No\IJtlk-oI Structure (pipe, ditch, etc. l `
Receiving Stream: Un ng m e A =4; h &jA -4e & b ( r-e�
Describe the industrial activities that occur within the outfall drainage area: \-:.'45- �X1114L .p,Pua
Szc\';ce— &„ ku
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: \--, 5VA
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak
chlorine odor, etc.): txone.
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and
5 is very cloudy: �
0 2 3 4 5
S. Floating Solids: Choose the number which best describes the amount of Floating solids in the
stormwater discharge, where 1 is no solids and 5 is the surface covered with Floating solids:
U 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
0 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes
8. Is there an oil sheen in the stormwater discharge? Yes C
9. Is there evidence of erosion or deposition at the outfall? Yes (�N
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may be
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SWU-242, Last modified 10/25/2012

W�A
NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling out thisform, please visit: httpi//portal.ncdenr.org/web/wq/ws/su/npdessw#tab-4
Permit No: N/C/GV6/0/0/0/0 or Certificate of Coverage No. N/C/G/0/6/0/0/2/0
Facility Name: Tyson Farms Inc.
County: Wilkes
Phone No: 336.838.2171
Inspector: James Brown
Date of Inspection: 07/22/2019
Time of Inspection: -?0'
Total Event Precipitation (inches): 0.32
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
YYes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be performed during a
"representative storm event" or during a "measureable storm event" However, some permits do not have this
requirement. Please refer to these definitions, if applicable. -
A "representative storm even[" is a storm event that measures greater than 0.1 inches of rainfall and that is preceded
by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
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. The 72-hour storm interval does not apply if the permittee is able to document that a shorter interval is
representative for local storm events during the sampling period, and the permittee obtains approval from the local DWQ
Regional Office.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
of Permittee or Designee)
Pagel of 2
SWU-242, Last modified 10/25/2012

1. Outfall Description: (�
Outfall NOV'( -Va Structure (pipe, ditch, etc.) Y n c
Receiving Stream: U11Bawled 1 r- hwfury .kb Cub NtC-[L
Describe the industrial activities that occur within the outfall drainage area: i)VFaL Wg-Ac Waku�r��,.,r �l
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: L-Zsha"
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak
chlorine odor, etc.): 11OhC
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and
5 is very cloudy:
01 2 3 4 5
S. Floating Solids: Choose the number which best describes the amount of Floating solids in the
stormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
�1 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
0 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes
8. Is there an oil sheen in the stormwater discharge? Yes l�1°
9. Is there evidence of erosion or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition maybe
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SWU-242, Last modified 10/25/2012

A�� r
MUM
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling out thisform, please visit: http_//portal ncdenr org/web/wq/ws/su/npdessw#tab-4
Permit No: N/C/G/0/6/0/0/0/0 or Certificate of Coverage No. N/C/G/0/6/0/0/2/0
Facility Name: Tyson Farms Inc
County: Wilkes
Phone No: 336.838.2171
Inspector: James Brown
Date of Inspection: 07/22/2019
Time of Inspection: V.8 5 -VM
Total Event Precipitation (inches): 0.32
Was this a "Representative Storm Event' or "Measureable Storm Event" as defined by the permit?
(Seeinformationbelow.)
(J Yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event"or "measureablestorm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be performed (luring a
11 representative storm event' or during a "measureablestorm event." However, some permits do not have this
requirement Please refer to these definitions, if applicable.
A "representative storm event"is a storm event that measures greater than 0.1 inches of rainfall and that is preceded
by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
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. The 72-hour storm interval does not apply if the permittee is able to document that a shorter interval is
representative for local storm events during the sampling period, and the permittee obtains approval from the local DWQ
Regional Office.
By this si I ture, l certify that this report is accurate and complete to the best of my knowledge:
of Permittee or Designee)
Pagel of 2
SW U-242, Last modified 10/25/2012

1. Outfall Description:
Outfall No. ;t --C Structure (pipe, ditch, etc.)
Receiving Stream: �itftLttrie�TC:ba�aty 4tp 1bt3`
activities that occur within the outfall drainage area:
k,fkcm jQWveL Elvrrcw QGCnLLuy Suk
2. Color: Describe the color of the disci
(light, medium, dark) as descriptors:
using basic colors (red, brown, blue, etc.) and tint
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak
chlorine odor, etc.): (1DY%G
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is clear and
5 is very cloudy:
2 3 4 5
S. Floating Solids: Choose the number which best describes the amount of Floating solids in the
stormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
0 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
01 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes 6
8. Is there an oil sheen in the stormwaterdischarge7 Yes G
9. Is there evidence of erosion or deposition at the outfall? Yes
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may be
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SWU-242, Last modified 10/25/2012

Wilkesboro Storm Water Calu. Sheet
Date 07/22/2019
Rain Begin: 5:20 PM light on and off
Run off started 5:50 AM
Grab Samples: 6:15 PM
Rain at end of
Storm Event: 0.32
Sampling Point # 1 Drainage Area = 140,800 Ft 2
Q = CIA
1 = .32 " (Total)
C = 1.0
Q = 1.0(.32/12)(140,800'7.5)/1,000,000
0.028 MG
Sampling Point # 2 Drainage Area = 578,250 Ft 2
Q = CIA
1 = .32 " (Total)
C = 1.0
Q = 1.0(.32/12)(578,250`7.5)/1,000,000
0.116 MG
Sampling Point # 3 Drainage Area = 578,250 Ft 2
Q = CIA
1 = .32 " (Total)
C=1.0
Q = 1.0(.32/12)(43,560-7.5)/1,000,000
0.009 MG

GPRISM
�QUBOPATOPIEa. LNG
Full -Service Analytical &
Environmental Solutions
Tyson Farms, Inc. -Wilkesboro, NC
James Brown
704 Factory Street
Wilkesboro, NC 28697
NC Certification No. 402
NC Drinking Water Cert No. 37735
SC Certification No. 99012
Project: Stormwater
Lab Submittal Date: 07/23/2019
Prism Work Order: 9070323
Case Narrative
8/5/19 11:59
This data package contains the analytical results for the project identified above and includes a Case Narrative, Sample
Results and Chain of Custody. Unless otherwise noted, all samples were received in acceptable condition and processed
according to the referenced methods.
Data qualifiers are flagged individually on each sample. A key reference for the data qualifiers appears at the end of this case
narrative.
Narrative Notes:
This is a Revised Report and supercedes the original laboratory report dated 08/02/19. Correction made
to client sample ID for sample 9070323-03.
Please call if you have any questions relating to this analytical report.
Respectfully,
PRISM LABORATORIES, INC.
Terri W. Cole
Project Manager
Data Qualifiers Key Reference
Reviewed By Terri W. Cole
Project Manager
HT Sample received and analyzed outside of the hold time.
OG HEM 0&G is less than the reporting limit, therefore TPH (SGT-HEM) is less than the reporting limit. Sample not
extracted for TPH (SGT-HEM).
BRL Below Reporting Limit
MDL Method Detection Limit
RPD Relative Percent Difference
Results reported to the reporting limit. All other results are reported to the MDL with values between MDL and
reporting limit indicated with a J.
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Box 240643 - Charlotte, NC 28224-0543
Phone: [phone] - Toll Free Number: t-8001529.6364- Fax: [phone] Page 1 of6

Sample Receipt Summary
�P R I S M
Full-Service4
Vv.oaxnronica ixa
en al Solutions
Environmental 6olutlona
08/05/2019
Prism Work Order: 9070323
Client Sample ID
Lab Sample ID
Matrix
Date/Time Sampled Date/Time Received
SW Wlk-01
9070323-01
Water
07/22/19 18:15 07/23/19 16:30
SW Wilk-02
9070323-02
Water
07/22/19 18:25 07/23/19 16:30
SW Wilk-03
9070323-03
Water
07/22/19 18:35 07/23/19 16:30
Samples were received in good condition at 3.9 degrees C unless otherwise noted.
I
This report should not be reproduced, except in its entirety, without the written consent of Priam Laboratories, Inc.
449 Springbrook Road - P.O. Box 240543 - Charlotte, NC 28224-0643
Phone: [phone] - Toll Free Number: 14001629.6364 - Fax: [phone] Page 2 of 6

C
�P R I S M I Fuei,lce elal .6erSiynca 4
enve men SOWtlorm
OAeon. Ruk 1�
Laboratory Report
08/05/2019
Tyson Farms, Inc. -Wilkesboro, NC
Project: Stormwater
Client Sample ID: SW WIk-01
Attn: James Brown
Prism Sample ID: 9070323-01
704 Factory Street
Prism Work Order: 9070323
Wilkesboro, NC 28697
Sample Matrix: Water
Time Collected: 07/22/19 18:15
Time Submitted: 07/23/19 16:30
Parameter
Result Units Report
MDL Dilution Method Analysis Analyst Batch
Limit
Factor DateRme ID
General Chemistry Parameters
Chemical Oxygen Demand
110
mg/L
50
10 1
'SM5220 D
7/26119 8:19
SLS
P9130430
Oil & Grease (SGT-HEM)
BRLOG
mg/L
5.0
1.6 1
'1664B
7/25/19 13:33
SLS
P9G0416
Total Suspended Solids
16
mg/L
6.2
0.70 1
'SM2640 D
7/29119 17:01
CBM
P9G0484
Microbiological Parameters
Fecal Colifonns
BRLHT
CFU/100 ml
2
1
'SM9222 D
7/23/19 17:15
BMS
P9G0436
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Box 240643 -Charlotte, NC 28224-0543
Phone: [phone] - Toll Free Number: l-800/629-6364-Fax: [phone] Page 3 0f 6

LP Full -Service Analytical 6
Environmental Solutions
Laboratory Report
08/05/2019
Tyson Farms, Inc. -Wilkesboro, NC
Project: Stormwater
Client Sample ID: SW W11k-02
Attn: James Brown
Prism Sample ID: 9070323-02
704 Factory Street
Prism Work Order: 9070323
Wilkesboro, NC 28697
Sample Matrix: Water
Time Collected: 07/22/19 18:25
Time Submitted: 07/23/19 16:30
Parameter
Result Units Report
MDL Dilution Method Analysis Analyst Batch
Limit
Factor DaterTime ID
General Chemistry Parameters
Chemical Oxygen Demand,
78
mg/L
60
10 1 'SM5220 D
7126/19 8:19
SLS
P9G0430
Oil 8, Grease (HEM)
6.2
mg/L
6.0
1.7 1 '1664B
7126/19 9:06
SLS
P9G0416
Total Suspended Solids
13
mg/L
5.0
0.70 1 'SM2640 D
7129/19 17:01
CBM
P9G0484
Microbiological Parameters
Fecal Coliforms
4 HT
CFU/100 ml
2
1 'SM9222 D
7/23/19 17:16
BMS
P9G0436
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Box 240543 - Charlotte, NC 28224-0643
Phone: [phone]-Toll Free Number: l-8001629.6364-Fax: [phone] Page 4 of 6

R
Full -Service AnalyticalsI S M I Environmental Solutions
Laboratory Report
08/05/2019
Farms, Inc. Wilkesboro, NC
Attn: James Brown
704 Factory Street
Wilkesboro, NC 28697
Project: Stormwater Client Sample ID: SW Wdk-03
Prism Sample ID: 9070323-03
Prism Work Order: 9070323
Sample Matrix: Water Time Collected: 07/22/19 18:35
Time Submitted: 07/23/19 16:30
Parameter Result Units Report MDL Dilution Method Analysis Analyst Batch
Limit Factor Date/Time ID
General Chemistry Parameters
Chemical Oxygen Demand
66
mg/L
5o
10 1
'SM6220 D
7126/19 8:19
SLS
P9G0430
Oil & Grease (HEM)
BRL
mg/L
5.0
1.7 1
'1664B
7/25/19 9:06
SLS
PgG0415
Total Suspended Solids
46
tri
6.0
0.70 1
'SM2640 D
7129/19 17:01
CBM
P930484
Microbiological Parameters
Fecal Coliforms
2800 HT
CFU/100 ml
2
1
'SM9222 D
7/23119 17:16
BMS
P9G0436
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Box 240643 - Charlotte, NC 28224-0643
Phone; 704/629-6364-Toll Free Number: l-900/52M364- Fax: [phone] Page 5 of 6

�e
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�`_ �`�'��M�*♦ CHAIN OF CUSTODY RECORD t i CuawuTmscs d�h INc 2'
t LJ ?J1.iC'Y�.`a.l EPACE —OF— QUOTE . TO ENSnaE R1eP[fl erLLlNe: CtSam(iGS INtACT YRerI0 �0YI�'j��� :«°-'Iic"'< y �
"I Sarvka Analytical d FnvvmmermW solu Wm J t { : ro
Project Name: ud0°ad ON WET ICE7,lTompl�-+ +.ai '^.*ir_'.a, �K Tl a
Ph Phone: [phone] ok d- P.O.ax04//52�olf_- note, NO �224-0513 Short Hold Analysis: (Yes) (No) UST Project P ER PRESERVATIVES rs;i
Y 1 (Yes) (No) LL>} �v T7
r 'Please ATTACH an t RsmivE. WIAAN NOLDINO TMEb7?1�-i'
Client Company Name: J. t1 C y project apecitic reporting (OC LEVEL I II 111 M ?. r mow, r .L f� V
provisions and/or OC Requirements aSOIIS ODY SEALS tAITALT7 L. C i
Report To/Contact Name: �n t1,.vt •�oW n yAVaa7tiE3�r c'awrotirH�nosvai��S;j' t"x
Invoice To: 'y
Reporting Atldress:�OLi' F-tY•�rr�. G.lrG C+.i PFIOPER CONTAINERS
Address: 'i`:'.•. t: trim::u.:..ccr.,•r�L`r.e•-tL:.�:...=e;
Email �" rs) (NO) Email Address,4nlrl.,S.-SDrv.rn Archaso Order No./Billing Reference TO BE FILLED IN BY CLIENT/SAMPLING PERSONNEL
�, e
Roque=od Due Dale 1Day 2Days 3Days 4Days 5Days Certification: NELACUSACE_FL_NC_
EDD Type:�PDF P-%cel_Othe� r •Worldng Days" 6-9 Days Standard days
Site Location Name: %3 • ( r; C Sn1-P"I1' S Samples received after IS:W w41 be processed next business day. SC_ OTHER N/A
Site Location Physical Address:` , - •rt Turnaround rime is based on business days, excluding "okends and holidays. Water Chlorinated: YES _ NO _
ISM REVERSE FOR TERMS A CONDITIONS REGARDING SERVICES Sample iced Upon Collection: YES NO
RENDERED BY PRISM IAB MMRME G. TO CDENT,
CLIENT
SAMPLE DESCRIPTION
DATE
COLLECTED
TIME
COLLECTED
MILITARY
MATRI%
(SOIL,
WATER OR
SAMPLE CONTAINER
PRESERVA.
TIVES
'TYPE
HOURS
SLUDGE)
SEE BELOW
NO.
SIZE
a
t
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