NCG060351_MONITORING INFO_20190725

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
AG O b D l
DOC TYPE
❑ HISTORICAL FILE
C� MONITORING REPORTS
DOC DATE
❑ �u
YYYYMMDD

STORMWATER DISCHARGE MONITORING REPORT
for North Carolina Division of Energy, Mineral and Land Resources General Permit No. NCG0600000 �^
Date submitted � t('�(—Z ECEI p
JUL 25 [d�9
CERTIFICATE OF �CpOVERAGE NQ NCGO 3 S p SAMPLE COLLECTION YEAR DE,NR_
FACILITY NAME Ir{G 41�,.ti,ti^�. �� ��� C't. C'KccGC TORP4WATERPUA.LITY
COUNTY - 5 (s ✓ SAMPLE PERIOD ❑ Jan -June ❑ July -Dec ERMITTING
PERSON COLLECTING AMPLErk o g A or ❑ Monthly' (month)
LABORATORY S ., n � t'r -v, Lab Cert. N if p DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
❑Zero -flow ❑Water Supply ❑SA
❑Other
FACILITY ACTIVITIES INCLUDE (check all that apply):
❑ use/process meats ❑ use animal fats/byproducts
Part A: Stormwater Benchmarks and Monitoring Results
PLEASE REMEMBER TO SIGN ON THE REVERSE -�,
Total event rainfallz,� lc) or ❑ N d' h l
Outfall No.
Date 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
o rsc urge t „� Vi f iuu
Enterococci,
Colonies per 100 ml
Benchmark
-
100 or 504
Within 6.0-9.0
120
30
10001
Soo,
Parameter Code
-
COS30
00400
00340
00556
31616
61211
N A
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.
'See General Permit text, Table 1, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
'Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new oil per month? ❑ yes Elmo
Permit Date:11/1/2018-05/31/2021
(if ves. complete Part R)
SWU-249, Last Revised 11/5/2018
Page 1 of 2

Part B: Vehicle Maintenance Area Monitorine Results: only for facilities averaging > SS gal of ngw mntnr nillm. ..th
Outfall No.
Date Sample Collected
(mo/dd/yr)
24-hour rainfall amount,
Inches2
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/O
Parameter Code
-
46529
NCOIL
00552
C0530
Footnotes from Part A also apply to Part B
'FOR PART A AND PART B MONITORING RESULTS:
• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART 11 SECTION B.
• 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART 11 SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an 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, 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 motions."
of Permittee
Permit Date: 11/1/2018-05/31/2021
2Z �
Date
SWU-249, Last Revised 11/5/2018
Page 2 of 2

ENVIRONMENTAL
ARMSERVICES, INC.
ASSESSMENT & REMEDIAL SERVICES DIVISION
July 12, 2019
Mr. Jason Reid
Mann - Hummel Filtration Technology
1551 Mount Olive Church Road
Gastonia, NC 28052
RE: Stormwater Sampling Results - North Carolina General Permit No. NCG060000
Certificate of Coverage Number NCG060351
1st Semi -Annual 2019 Sampling RECEIVED
Wix Master Distribution Center ""
1551 Mount olive church Road JUL 25 2019
ARM Project No. 12-4028-14
DENR-LAND QUALITY
Dear Mr. Reid: STORMWATER PERMITTING
In accordance with the North Carolina Department of Environment, and Natural Resources (NC
DENR) stormwater discharge permit. ARM collected semi-annual stormwater samples at the
referenced facility on June 7, 2019.
The samples consisted of three stormwater grab samples from the facility stormwater outfall
locations, and the samples were collected during the rain event in clean, pre -preserved,
laboratory -prepared sample bottles. The samples were then delivered to Prism Laboratories,
Inc., which is a North Carolina -accredited analytical laboratory. The samples were analyzed for
oil and grease, total suspended solids (TSS), and chemical oxygen demand (COD), per the
permit requirements.
The attached Table 1 provides a summary of the analytical results (also attached), total flow, and
total rainfall. All parameters were below the permitted range benchmarks for all three outfalls. The
pH was performed in the field upon sample collection; was within the recommended holding time of
15 minutes: and showed results within the permitted range benchmark value of 6.0-9.0. The
Stormwater Discharge Monitoring Report (SDO), which also shows the analytical results for the
outfalls is attached. During sample collection, qualitative monitoring of certain parameters was
performed and the Qualitative Monitoring Report for each outfall is attached.
ARM appreciates the opportunity to provide environmental services to Mann -Hummel. As required
by the stormwater permit, please sign the second page of the SDO and then forward the report to
the NC DENR-Central Files at the Division of Energy, Mineral, and Land Resources in the
addressed envelope provided. Please call us at 704-369-0621, if you have any questions.
Sincerely,
ARM Environmental Services, Inc.
Tim�McCorkle
Project Manager
cc: Central Files, DENR-Division of Energy, Mineral, and Land Resources
11164 DOWNS ROAD, PINEVILLE, NC 28134 / [phone] fax [phone] / www.armenv.com

Table 1. Stormwater Sampling Results
Stormwater
Parameters
Units
Outfall1
Outfall2
Outfall3
Benchmark
Oil And Grease
mg/L
ND
19
ND
30
pH
S.U.
6.0-field
6.5-field
6.5-field
Within 6.0-9.0
Total
Suspended
Solids
mg/L
3.4
14
76
100
COD
mg/L
ND
NO
NO
120
Total Rainfall
inches
2.10
2.10
2.10
Storm Duration
minutes
600
600
600
Total Flow
gallons/
minute
70
30
40
ND = Not Detected
mg/L = micrograms per liter (parts per million equivalent)
s.u.= standard pH units

F.'nvirunmcnfu/
Quality
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out drisfonn, please visit https://deq.nc.goN,/about/divisions/energy-mineral-land-resources/
npdes-stomiwatcr-gps
Permit No.: V/C/GJ; j / (r./0!O/O / or ertificate of Coverage No.: 1\JC/G/p/6r tD? 3
Facility Name: Mj
County: � s4ct., r.
n Phone No.
Inspector: e , ti
Date of Inspection: 4-!7 / LT
Time of Inspection:
Total Event Precipitation (inches) (_, / o
All pennits require qualitative monitoring to be performed during a "measurable storm event."
A `measurable storm event" is a storm event that results in an actual discharge from the permitted site
oulfall. 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 DEMLR
Re-aional Office.
By thit�grtature. I certify that this report is accurate and complete to the best of my knowledge:
or Designee)
I. Outfall Description:
Outfall No. ' .2 Structure (pipe, ditch, etc.):
Receivi>vStream:
Describe the industrial activities th t o cur within the outfall drainage area
Page I oft
�lk ✓41��
SW'ii-24R. Last modified W0112018

2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors:
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil, weak
chlorine odor, etc.): 10 L`ltiC
4. Clarity: Choose the number which best describes the clarity of the discharge. where I is clear
and 5 is very cloudy:
`/ 2 3 4 i
5. 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:
(� 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended solids in
the stormwater discharge, where I is no solids and 5 is extremely muddy:
1 1 2 3 4 5
7. Is there any foam in the storm«ater discharge? o Yes ®No.
8. Is there an oil sheen in the stormwater discharge? oyes ® No.
9. Is there evidence of erosion or deposition at the outfall? O Yes 40 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 may be
indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SwU-242. fast modified 06 01/2018

E'mirunmeatui
Quality
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this./brm, Please visit https:!/deq.nagov/about/divisions/energy-mineral-land-resources/
np des-stormwater-gps
Permit No.: N/C/,('_v'016,101 p1,o101 or C rtificate of Coverage No.:j
Facility Name:
County: �.i�.—., �
4 -� / Phone No.
Inspector: / /.,7Cj 1v
Date of Inspection:
Time of Inspection:
Total Event Precipitation (inches): .-. / n
All permits require qualitative monitoring to be performed during a "measurable storm event."
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 pennittee 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 DEMLR
By this shmature. I certitiv that this report is accurate and complete to the best of my knowledge:
5
of Permittee or Designee)
1. Outfall Description:
Outfall No,/j D -)—
Receiving Stream: n
Structure (pipe, ditch; etc.):!
Paae I of 2
S%VU-242. Last modified OG/UI@OlR

2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: Ll�� n
3. Odor: Describe any distinct odors that the discharge may ha%e (i.e.. smells strongly of oil. weak
chlorine odor, etc.): i'1ti�-.
4. Clarity: Choose the number which best describes the clarity of the discharge, where I is clear
and 5 is very cloudy: /
2 3 4 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stormwater discharge, where I is no solids and 5 is the surface covered with floating solids:
71 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:
2 3 4 5
7. Is there any foam in the stormwater discharge? O Yes 0 No.
8. Is there an oil sheen in the stormwater discharge? OYes 0 No.
9. Is there evidence of erosion or deposition at the outfail? O Yes 0 No.
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
[Vote: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition may be
indicative of pollutant exposure. These conditions „arrant further investigation.
Page 2 of 2
SwU-242. Lase modified 06,0112018

Elmtranmcntu(
Qual(ty
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this,/brm, please visit htips://deq.ne.goy/aboutldiN isions/energy-mineral-land-resources/
npdes-stomtwa ter-gps
PermitNo.: N/C/O 16,101010101 or/Ce rcateofCoverage
7No.: NN//C/G/O(
Facilitv Name. gLt, L,
Phone No. 70� O �9(9
Inspector-,
Date of Inspection: k-7 // `I
Time of Inspection: / y ,
Total Event Precipitation (inches): ,.�, / O
_.----------._.._----
All permits require qualitative monitoring to be performed during a "measurable storm event."
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 pennittee obtains approval from the local DEMLR
Regional Office.
By this e, I certify that this report is accurate and complete to the best of my knowledge:
(Signature of Permittee or Designee)
1. Outfall Description:
Outfall No. ) Structure (pipe, ditch, etc.):
Receiving Stream: / // 1_ // J // '/
IY - &z&vl�'.( 1� l./ / Cl.%��-�_' l C�-Y,Iii ��C. \.: I4 Vi .^ Y t NLL. ! L.I /I.L . C
Describe the
occur wit tfi the outfall d-frainage area: F
.". ,._- -. vi_. n /—, ,,,� .(.
Page 1 of
Stty-242. Last modified 06101120 18

2. Color: Describe the color of thg
(light, medium, dark) as descriptors: _
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):
4. Clarity: Choose the number which best describes the clarity of the discharge, where I is clear
and 5 is very cloudy:
11__ 2 3 4 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in the
stomnvater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
D 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:
2 3 4 5
Is there any foam in the stormwater discharge? o Yes A No.
Is there an oil sheen in the stormwater discharge? OYes ® No.
Is there evidence of erosion or deposition at the outfall? o Yes ® No.
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 OW0112018

Full -Service Analytical &
ISM I Environmental Solutions
A07LABORATORIEB, INC.
ARM Environmental - Charlotte
Tim McCorkle
11164 Downs Rd.
Pineville, NC 28134
NC Certification No. 402 Case Narrative
NC Drinking Water Can No. 37735 6/19/19 12:43
SC certification No. 99012
Project: Mann -Hummel Mt. Olive Church Plant
Lab Submittal Date: 06/07/2019
Prism Work Order: 9060127
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.
Please call if you have any questions relating to this analytical report.
Respectfully,
PRISM LABORATORIES, INC.
( " //.W o lN—�—
Terri W. Cole
Project Manager
Data Qualifiers Key Reference
Reviewed By Jackie Ziner For Terri W. Cole
Project Manager
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] - Totl Free Number: 1-8001629-6364 - Fax: [phone] Page 1 of 7

`
I� �I I Fuviron lco Analytical 8i-P2RIS uw,unes ixc Environmentm Sahnio^a
Sample Receipt Summary
06/19/2019
Prism Work Order: 9060127
Client Sample ID
Lab Sample ID
Matrix
Date/Time Sampled Date/Time Received
001
9060127-01
Water
06/07/19 15:00 06/07/19 16:10
002
9060127-02
Water
06/07/19 14:50 06/07/19 16:10
003
9060127-03
Water
06/07/19 14:43 06/07/19 16:10
Samples were received in good condition at 4.2 degrees C unless otherwise noted.
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: [phone]-Toll Free Number: 1-8001529-6364 - Fax: [phone] Page 2 of 7

/P PR I S M l rull.Somice Analyncel &
h Emironmxmal Saint[...
Laboratory Report
06/19/2019
ARM Environmental - Charlotte
Project: Mann -Hummel Mt. Olive
Client Sample ID: 001
Attn: Tim McCorkle
Church Plant
Prism Sample ID: 9060127-01
11164 Downs Rd.
Prism Work Order: 9060127
Pineville, INC 28134
Sample Matrix: Water
Time Collected: 06/07/19 15:00
Time Submitted: 06/07/19 16:10
Parameter
Result Units Report MOIL
Dilution Method Analysis Analyst Batch
Limit
Factor Date/Tlme ID
General Chemistry Parameters
Chemical Oxygen Demand BRL ni 50 10 1 'SM5220 D 6112/19 11:15 SLS P9F0180
Oil & Grease (HEM) BRL mg/L 5.0 1.7 1 9664B 6/18/19 820 SLS P91`0268
Total Suspended Solids 3.4 mglL 2.6 0.70 1 'SM2540 D 6112119 9:45 SLS P9F0169
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Boa 240543 - Charlotte, NC 28224-0543
Phone: [phone] - Toll Free Number: 1-800/629-6364 - Fax: [phone] Page 3 OI 7

&Q,�)Q—I S M I FWbservica Analyticala
Environmental Solution&
umn�muieA m�.
Laboratory Report
0611912019
ARM Environmental - Charlotte
Project: Mann -Hummel Mt. Olive
Client Sample ID: 002
Attn: Tim McCorkle
Church Plant
Prism Sample ID: 9060127-02
11164 Downs Rd.
Prism Work Order: 9060127
Pineville, NC 28134
Sample Matrix: Water
Time Collected: 06/07/19 14:50
Time Submitted: 06/07/19 16:10
Parameter
Result Units
Report
MDL
Dilution Method Analysis Analyst
Batch
Limit
Factor Datefrme
ID
General Chemistry Parameters
Chemical Oxygen Demand
BRL mg/L
50
10
1 'SM5220 D 6112/19 11:15 SLS
P91`0180
Oil & Grease (HEM)
19 mglL
5.0
1.7
1 '1664B 6/18119 8:20 SLS
P91`0268
Total Suspended Solids
14 mg1L
2.5
0.70
1 'SM2540 D 6/12119 9:46 SLS
P9F0169
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 28224-0543
Phone: [phone]- Toll Free Number: 1-8001629-6364 - Fax: [phone] Page 4 0f 7

'PRISM Ful ironer ca Analytical 4
/ 1 Environmemal Solutions
..ao..,a.Ixa, c..
ARM Environmental - Charlotte
Attn: Tim McCorkle
11164 Downs Rd.
Pineville, NC 28134
Project: Mann -Hummel Mt. Olive
Church Plant
Sample Matrix: Water
Laboratory Report
06/1912019
Client Sample ID: 003
Prism Sample ID: 9060127-03
Prism Work Order: 9060127
Time Collected: 06/07/19 14:43
Time Submitted: 06/07/19 16:10
Parameter
Result
Units
Report
Limit
MOIL
Dilution
Factor
Method
Analysis
DateRme
Analyst
Batch
ID
General Chemistry Parameters
Chemical Oxygen Demand
BRL
mg/L
50
10
1
'SM5220 D
6/12/19 11:15
SLS
P91`0180
Oil & Grease (HEM)
BRL
mg/L
5.0
1.7
1
-1664B
6/18/19 8:20
SLS
P9F0268
Total Suspended Solids
76
mg/L
6.2
0.70
1
'SM2540 D
6112119 9:45
SLS
PSF0169
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: 1-8001629-6364 - Fax: 704I626-0409 Page 5 of 7

R I SpM I Full-Sorvico Analytical b
•nnnnm en ,K Envlronmenlal Solutitlons
ARM Environmental - Charlotte
Attn: Tim McCorkle
11164 Downs Rd.
Pineville, NC 28134
General Chemistry Parameters - Quality Control
Analyze
Batch P91F0169 - NO PREP
Project: Mann -Hummel Mt. Olive Church
Plant
Level II QC Report
6/19/19
Prism Work Order: 9060127
Time Submitted: 6/7/2019 4:10:OOPM
Reporting Spike Source %REC RPD
Result Limit Units Level Result %REC Limits RPD Limit Notes
Blank (P9F0169-BLK1) Prepared & Analyzed: 06/12/19
Total Suspended Solids BRL 5.0 mg/L
LCS (P9F0169-SS1) Prepared & Analyzed: 06/12/19
Total Suspended Solids 470 5.0 mg/L 477.0 99 90-110
Batch P9FO180 - NO PREP
Blank (P9F0180-BLK1) Prepared & Analyzed: 06/12/19
Chemical Oxygen Demand BRL 50 mg/L
LCS (P9F0180-BSI) Prepared &Analyzed: 06/12/19
Chemical Oxygen Demand 486 50 mg/L 500.0 97 90-110
Matrix Spike (P9F0180-NISI)
Source: 9060127-01
Prepared &Analyzed: 06/12/19
Chemical Oxygen Demand
483 50 mg/L
500.0 BRL 97 80-120
Matrix Spike Dup (P9F0180-MSD1)
Source: 9060127-01
Prepared & Analyzed: 06/12/19
Chemical Oxygen Demand
484 50 mg/L
500.0 BRL 97 80-120 0.2 20
Batch P9FO268 - NO PREP
Blank (P9F0268-BLK1)
Prepared & Analyzed: 06/18/19
Oil & Grease (HEM)
BRL 5.0 mg/L
LCS (P9F0268-BS1)
Prepared & Analyzed: 06/18/19
Oil & Grease (HEM)
144 5.0 mg/L
160.0 90 78-114
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, INC 28224-0543
Phone: [phone]-Toll Free Number: 1-8001529-6364-Fail: 7041626-0409 Page 6o 77

I`- � /, I Full -Service Analytical s
J'v' Environmental Solutions
///e�UBJAAip11LX 1rN.'.
449 Springbrook Road - Charlotte, NC 28217
Phone [phone] • Farx�7041525-0409
Client Company Name:+ G tJS�AtL`�.Y,�2.
Report To/Contact Named C' ',.fib
Reporting Wress: 1 (-.l /.a Clh�C
CHAJN OF CUSTODY RECORD
PAGE- O .rVI000TE 0 TO ENSURE ROPER
BILLING.
Project Name:
Short Hold Analysis: (Yes) (No) UST Project: (Yes) (NO)
*Please ATTACH any project specific reporting (QC LEVEL 111111 11f)
provisions andn//onr//r OC Requirements
Invoice To:L�
Address: oiLx�P /XG A�}P
YES NO
Samples INTACT upon arrival?
Received ON WET ICE?,
PROPER PRESERVATIVES indicated?'
Received WITHIN HOLDING TIMES?
CUSTODY SEALS INTACT?
�• VOLATILES reed WIOUT HEADSPACE?
-
PROPER CONTAINERS Usad9
' TEMP: Therm JD. t fLl'.-3 Observetl
11' C In:
r
'` -' Purchase Order NodBilling Reference
Email Address 101-11 -c.�rK�e-.F% /nt - -
c�'Requestad Due Date o 1 Day `ti z Days ❑ 3 Days 04 Days O 5 Days
EDD Type: PDF Excel Other. "WIvi n, Days. O6-9 Days OStandard l0 days O Rush Work MUst Be
Site Location Name: L�10.r.A -{A`� C x ss day.provetl
received after 14:OD will be processed next business day.
Q4.. I ..^'Y rt'Ph:% in^r Add,-Bss: _ Turnaround time is based on business days, excluding weekends and holidays.
L �1 �I l ` (. (SEE REVERSE FOR TERMS 6 CONDITIONS REGARDING SERVICES
l RENDERED BY PRISM LABORATORIES, INC. TO CLIENT)
TO BE FILLED IN BY CLIENT/SAMPLING PERSONNEL
Certification: NELAC DOD FL NC
_
SC OTHER _ N/A
Water Chlorinated: YES NO
-
Sample Iced, Upon Collection: YES NO -
CLIENT
SAMPLE DESCRIPTION
DATE
COLLECTED
;_
TIME
COLLECTED
� MILRARY
HOURS
MATRIX
(SOIL,
WATER OR
SLUDGE)
I - SAMPLE
CONTAINER
PRESERVA-
1�(C,,�� ANALYSIS REQUESTED _
!// / e REMARKS
e- �'- 6-
PRISM
LAB
ID NO.
(Z
-TYPETNES
SEE BELOW
NO.
SIZE
2.
l
I
i
Sampler's Sign re "' I Sampled By (Print Name) Affiliation AlgeA
requested I above. Any changes must De '
Upon relinquld ,.thie Chan m Custody is -you r authorization b for Prism to proceed with the analyses as have
submitte inp t the Prism Project Manager., There will De charges for any changes after analyses have been Initialized. _ - -
Rellnpuk)11 (slgnamm)• - _, ows AddibonalComments; Site AnwalTime:
16
'sLeO BYa �g tore) xd BY (Signs e) are - Site Departure Time:
Ra0ngw50etl By: (aigreWre) WivtM of Priam Leaeml0de5 ey/' Dale / Field Tech Fee.
/ �• �C9 �V Mileage: ,� ...
RH CDIL REC SEAL SF OR RA PORTATION IN BORA _ GroUpN, - • _
.MattwC of ShipmonC NOTE:ALL SAM PLECOOEPTED A D D VERIFIED AGAINST
SAMPLES ARE NOT ACCEPTED AND VERIFIED AGgINST CDC UNTIL RECEIVED AT THE ORATORY.: � -
❑ Fed Ex O UPS D HarbE(ad O Pdsm Feld Service ❑ Ole
1O
NPDES:UGROUNDWATER: DRINKING CE.BCOSCDOTHER:
ONC O SCI ONC O SC El NCO SCQNC ❑ S❑ NC ❑ SO NC O SC I ONEl oN J SONC
- IH SC
❑ I 1_
wn'r JN=K I Tre cuuts: A = Amber c = clear G= Glass P = Plastic; TL = Teflon -Lined Cap VOA = Volatile Organics Analysis (Zero Head Space) ORIGINAL