NCG100023_MONITORING INFO_20191112

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
14C G 1 00 a
DOC TYPE
❑ HISTORICAL FILE
L MONITORING REPORTS
DOC DATE
❑ 00 7 I I Q
YYYYM M D D

Mid Atlantic
Engineering & Environmental Solutions
October 10, 2019
NCDEQ/DWR
Attention: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
RECEIVE®
NOV 12 2019
CENT RAL FILES
DWR SECTION
Subject: STORMWATER SAMPLING RESULTS
M 8t M MOTOR COMPANY, INC.
9316 US HIGHWAY BUSINESS 220 NORTH
RANDLEMAN, RANDOLPH COUNTY, NORTH CAROLINA
PERMIT NUMBER NCGl00023
MID -ATLANTIC JOB NO. 00OR2005.00
To Whom It May Concern:
409 Rolm VlQW Court
Raleigh, NC 27610
office 919.15D."1a
6a'mile 919.250.99S0
MAAONLINE.COM
Attached please find the Stormwater Discharge Monitoring Report (DMR) and analytical
report for the sampling conducted at the above -referenced site. Stormwater samples
were collected from Outfalls 001, 002 and 003 on August 22, 2019 and analyzed for total
suspended solids (TSS), pH, total recoverable lead and oil and grease. As indicated on
the attached DMR, all parameters were reported below or within their respective
benchmark values for all three outfalls. If you have any questions or need additional
information, please contact me at 919-250-9918.
Sincerely,
MID -ATLANTIC ASSOCIATES, INC.
Ron Davis
Stormwater Services Manager
Attachments: Stormwater Discharge Monitoring Report
Laboratory Analytical Report
EXPERIENCED CUSTOMER FOCUSED INNOVATIVE

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
CERTIFICATE OF COVERAGE NO. NCGl00023
FACILITY NAME M&M Motor Company, Inc., Randleman, NC
PERSON COLLECTING SAMPLE(S) Heath McCaskill
CERTIFIED LABORATORY(S) Pace Analytical Lab #12
Lab #
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLES COLLECTED DURING CALENDAR YEAR:2019
COUNTY Randolph
PHONE NO. [phone]
PLEASE REMEMBER TO SIGN ON THE REVERSE 4
For sampling periods with no discharge, you must submit this discharge monitoring form noting "No Flow' or "No Discharge" within
30 days of the end of that period to comply with permit reporting requirements.
Outfall
No.
Date
Sample Collected,
mo/dd/year
Total
Rainfall,
inches
00400
00530
----
77023
01051
78141
pH,
Standard
Units
Total Suspended
Solids (TSS),
mg/L
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), mg/L
Ethylene Glycol,
mg/L
Lead, Total
Recoverable,
mg/L
Total Toxic
Organics3,
mg/L
Benchmark
-
-
6.0 — 9.01
100/502
15
8,000
(Tiers 2 and 3)
0.03
1.0
Outfall001
08/22/19
7.34
7.6
<4.9
<5.0
<0.005
NA
Outfall002
08/22/19
7.48
8.0
<4.9
<5.0
<0.005
NA
Outfall003
08/22/19
S
7.46
8.2
<4.9
<5.0
<0.005
NA
Note: If you report a sampled value in excess of the benchmark value, or outside the benchmark range for pH, you must implement Tier 1 or I ter i responses in the Generai
Permit.
1See If pH values outside this range are recorded in sampled stormwater discharges, but ambient precipitation PH levels are lower, then the lower threshold of this benchmark
range is the PH of the precipitation (within instrument accuracy)instead of 6 S.U. Readings from an on -site or local rain gauge (or local precipitation data) must be documented
to demonstrate background concentrations were below the benchmark pH range of 6-9.
2See General Permit text to identify whether the more protective benchmark applies for especially sensitive receiving waters.
3For purposes of this permit the definition of Total Toxic Organics is that list as stated in Appendix D, Table II of Chapter 40 Code of Federal Regulations (CFR) Part 122.
Form SWU-251, last revised October 25, 2012
Page 1 of 2

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan may request that DWQ waive monitoring of total toxic organics. 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 allowed such a waiver, the
discharger shall sign the following certification statement:
Solvent Management Plan 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 all the provisions of the solvent
management plan included in the Stormwater Pollution Prevention Plan."
Name (Print name)
Title (Print title)
Signature
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 MailServiceCenter
Raleigh, North Carolina27699-1617
Date
"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 a nd belief, true, accurate, and complete.
am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
(Signature of Permittee or Designee)
i-0
(Date)
Form SWU-251, last revised October 25, 2012
Page 2 of 2

acmnalytical
wewpecelab&=
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
September 05, 2019
Chuck Hoffman
Mid -Atlantic Associates, Inc
409 Rogers View Court
Raleigh, NC 27610
RE: Project: M&M Motor Company
Pace Project No.: 92442796
Dear Chuck Hoffman:
Enclosed are the analytical results for sample(s) received by the laboratory on August 26, 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,
i_ .< ��
Illlllr
Tyriek Hooks
[e-mail]
[phone]
Project Manager
Enclosures
cc: Ron Davis, Mid Atlantic Associatees, Inc.
*440RAWF
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, I.I.C.
Page 1 of 15

aceAnalytical
w ..pscelaos.com
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Project: M&M Motor Company
Pace Project No.: 92442796
Indiana Certification IDs
7726 Moller Road, Indianapolis, IN 46268
Illinois Certification #: 200074
Indiana Certification M C-49-06
Kansas/NELAP Certification #: E-10177
Kentucky UST Certification #: 80226
Kentucky WW Certification #: 98019
Michigan Department of Environmental Quality, Laboratory
#9050
Charlotte Certification IDs
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
Louisiana/NELAP Certification # LA170028
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
Asheville Certification IDs
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification M E87648
Massachusetts Certification #: M-NC030
North Carolina Drinking Water Certification #: 37712
CERTIFICATIONS
Ohio VAP Certification #: CL0065
Oklahoma Certification #: 2018-101
Texas Certification #: T104704355
West Virginia Certification #: 330
Wisconsin Certification #: 999788130
USDA Soil Permit #: P330-16-00257
South Carolina Certification #: 99006001
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
VirginiaNELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
VirginiaNELAP Certification #: 460222
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC. Page 2 of 15

aceAnalytical e
a vpawlos.cae
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Project: M&M Motor Company
Pace Project No.: 92442796
Lab ID Sample ID
92442796001 Outfall No.1
92442796002 Outfall No.2
92442796003 Outfall No.3
SAMPLE ANALYTE COUNT
Method
Analysts
Analytes
Reported
Laboratory
EPA 16648
JMS
1
PASI-C
EPA 8015 Alcohol -Glycol
CPH
1
PASI-I
EPA6010D
DS
1
PAST -A
SM 254OD-2011
NAL
1
PASI-A
EPA 1664E
JMS
1
PASI-C
EPA 8015 Alcohol -Glycol
CPH
1
PASI-I
EPA 601 OD
IDS
1
PASI-A
SM 254OD-2011
NAL
1
PASI-A
EPA 1664B
JMS
1
PASI-C
EPA 8015 Alcohol -Glycol
CPH
1
PASI-I
EPA6010D
DS
1
PASI-A
SM 254OD-2011
NAL
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 15

aceAnalytical
www.pemlebs.cwn
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
ANALYTICAL RESULTS
Project: M&M Motor Company
Pace Project No.: 92442796
Sample: Outfall No.1 Lab ID: 92442796001 Collected: 08/22/19 05:23 Received: 08/26/19 09:05 Matrix: Water
Parameters Results Units Report Limit OF Prepared Analyzed CAS No. Oual
1664 SGT-HEM, TPH Analytical Method: EPA 1664E
Total Petroleum Hydrocarbons ND mg/L 4.9 1 08/29/19 06:18
8015M Glycols in water Analytical Method: EPA 8015 Alcohol -Glycol
Ethylene glycol NO mg/L 5.0 1 0812811919:05 107-21-1
6010 MET ICP Analytical Method: EPA 6010D Preparation Method: EPA 3010A
Lead ND ug/L 5.0 1 09/03/1919:03 09/0411917:26 7439-92-1
2540D Total Suspended Solids AnalyBcal Method: SM 2540D-2011
Total Suspended Solids 7.6 mg/L 2.6 1 08/29/19 10:46
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 09/05/2019 12:30 AM without the written consent of Pace Analytical Services, LLC. Page 4 of 15

JoceAnalyficalo
w ..paoelabs.cvrn
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
ANALYTICAL RESULTS
Project: M&M Motor Company
Pace Project No.: 92442796
Sample: Outfall No.2 Lab ID: 92442796002 Collected: 08/22/19 05:38 Received: 08/26/19 09:05 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Oual
1664 SGT-HEM, TPH Analytical Method: EPA 1664E
Total Petroleum Hydrocarbons ND mg/L 4.9 1 08/29/19 06:18
8015M Glycols in water Analytical Method: EPA 8015 Alcohol -Glycol
Ethylene glycol ND mg/L 5.0 1 08/28/19 18:46 107-21-1
6010 MET ICP Analytical Method: EPA 6010D Preparation Method: EPA 3010A
Lead ND ug/L 5.0 1 09/0311919:03 09104/1917:29 7439-92-1
2540D Total Suspended Solids Analytical Method: SM 2540D-2011
Total Suspended Solids 8.0 mg/L 2.6 1 08/29/19 10:46
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 09/05/2019 12:30 AM without the written consent of Pace Analytical Services, LLC. Page 5 of 15

aceAnalytical e
w ..pacelaes.mrn
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
ANALYTICAL RESULTS
Project: M&M Motor Company
Pace Project No.: 92442796
Sample: Outfall No.3 Lab ID: 92442796003 Collected: 08/22/19 05:28 Received: 08/26/19 09:05 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Oual
1664 SGT-HEM, TPH Analytical Method: EPA 1664B
Total Petroleum Hydrocarbons ND mg/L 4.8 1 08/29/19 06:19
8015M Glycols in water Analytical Method: EPA 8015 Alcohol -Glycol
Ethylene glycol ND mg/L 5.0 1 08/28/19 18:56 107-21-1
6010 MET ICP Analytical Method: EPA 601 OD Preparation Method: EPA 3010A
Lead ND ug/L 5.0 1 09/03/19 19:03 09/04/19 17:38 7439-92-1
2540D Total Suspended Solids Analytical Method: SM 2540D-2011
Total Suspended Solids 8.2 mg/L 2.6 1 08/29/19 10:47
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 09/05/2019 12:30 AM without the written consent of Pace Analytical Services, L-C.
Page 6 of 15

aceAnalytical
wawpace/abs.com
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
QUALITY CONTROL DATA
Project: M&M Motor Company
Pace Project No.: 92442796
QC Batch: 495072
Analysis Method:
EPA 1664B
QC Balch Method: EPA 1664B
Analysis Description:
1664 SGT-HEM, TPH
Associated Lab Samples: 92442796001, 92442796002, 92442796003
METHOD BLANK: 2667482
Matrix: Water
Associated Lab Samples: 92442796001, 92442796002, 92442796003
Blank Reporting
Parameter
Units
Result Limit
Analyzed Qualifiers
Total Petroleum Hydrocarbons
mg/L
NO 4.8 08/29/19 06:09
LABORATORY CONTROL SAMPLE:
2667483
Spike LCS
LCS % Rec
Parameter
Units
Conc. Result
% Rec Limits Qualifiers
Total Petroleum Hydrocarbons
mg/L
19.2 19.5
101 64-132
MATRIX SPIKE SAMPLE:
2667484
92442234002 Spike
MS MS % Rec
Parameter
Units
Result Conc.
Result % Rec Limits Qualifiers
Total Petroleum Hydrocarbons
mg/L
NO 19.2
20.0 101 64-132
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: 09/05/2019 12:30 AM without the written consent of Pace Analytical Services, L-C.
Page 7 of 15

aceAnalytical'
wwwpacelabs.cwn
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
QUALITY CONTROL DATA
Project: M&M Motor Company
Pace Project No.: 92442796
QC Batch: 518926 Analysis Method: EPA 8015 Alcohol -Glycol
QC Batch Method: EPA 8015 Alcohol -Glycol Analysis Description: EPA 8015 Modified
Associated Lab Samples: 92442796001, 92442796002, 92442796003
METHOD BLANK: 2393596 Matrix: Water
Associated Lab Samples: 92442796001, 92442796002, 92442796003
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Ethylene glycol mg/L NO 5.0 08/28/19 17:42
LABORATORY CONTROL SAMPLE: 2393597
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Ethylene glycol mg/L 25 20.1 81 48-150
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2393598 2393599
MS MSD
92442796001 Spike Spike MS MSD MS MSD % Rec
Parameter Units Result Conc. Conc. Result Result % Rec e/ Rec Limits RPD Qual
Ethylene glycol mg/L ND 25 25 22.0 30.5 88 122 34-153 32 R1
Results presented on this page are in the units indicated by the'tlnits' 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: 09/05/2019 12:30 AM without the written consent of Pace Analytical Services. LLC.
Page 8 of 15

aceAnalytical"
wwwpacelaextArn
QUALITY CONTROL DATA
Project: M&M Motor Company
Pace Project No.: 92442796
QC Batch: 495754 Analysis Method: EPA 601 OD
QC Batch Method: EPA 3010A Analysis Description: 6010 MET
Associated Lab Samples: 92442796001, 92442796002, 92442796003
Pace Analytical Services, LLC
9800 Kinsey Ave. Suite 100
Huntersville, NC 28078
[phone]
METHOD BLANK: 2670857
Matrix:
Water
Associated Lab Samples: 92442796001, 92442796002, 92442796003
Blank
Reporting
Parameter
Units
Result
Limit
Analyzed Qualifiers
Lead
ug/L
ND
5.0
09/04/19 16:23
LABORATORY CONTROL SAMPLE:
2670858
Spike
LCS
LCS %Rec
Parameter
Units
Conc.
Result
% Rec Limits Qualifiers
Lead
ug/L
500
483
97 80-120
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2670859
2670860
MS
MSD
92442359001 Spike
Spike
MS
MSD MS MSD % Rec
Parameter Units Result Conc.
Conc.
Result
Result % Rec % Rec Limits RPD Qual
Lead ug/L ND 500
500
499
491 100 98 75-125 2
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: 09/05/2019 12:30 AM without the written consent of Pace Analytical Services, L-C.
Page 9 of 15

ace Analytical
wwwpacelab&com
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersvilte, NC 28078
[phone]
QUALITY CONTROL DATA
Project: M&M Motor Company
Pace Project No.: 92442796
OC Batch: 495128
Analysis Method:
SM 2540D-2011
QC Batch Method: SM 2540D-2011
Analysis Description:
2540D Total Suspended Solids
Associated Lab Samples: 92442796001, 92442796002, 92442796003
METHOD BLANK: 2667750
Matrix:
Water
Associated Lab Samples: 92442796001, 92442796002, 92442796003
Blank
Reporting
Parameter
Units
Result
Limit
Analyzed Qualifiers
Total Suspended Solids
mg/L
ND
2.5 08/29/19 10:43
LABORATORY CONTROL SAMPLE: 2667751
Spike
LCS
LCS % Rec
Parameter
Units
Conc.
Result
% Rec Limits Qualifiers
Total Suspended Solids
mg/L
250
242
97 90-110
SAMPLE DUPLICATE: 2667767
92442898001
Dup
Parameter
Units
Result
Result
RPD Qualifiers
Total Suspended Solids
mg/L
240
225 6 D6
SAMPLE DUPLICATE: 2667768
92442786002
Dup
Parameter
Units
Result
Result
RPD Qualifiers
Total Suspended Solids
mg/L
259
343 28 D6
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: 09/05/2019 12:30 AM without the written consent of Pace Analytical Services, LLC.
Page 10 of 15

aceAnalytical
a ..pawlebs.=
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
QUALIFIERS
Project: M&M Motor Company
Pace Project No.: 92442796
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.
PQL - Practical Quantitation 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 EPAguidelines, unrounded data are displayed and have been used to calculate % recovery and RPD values.
LCS(D) - Laboratory Control Sample (Duplicate)
MS(D) - Matrix Spike (Duplicate)
DUP - Sample Duplicate
RPD - Relative Percent Difference
NC - Not Calculable.
SG - Silica Gel - Clean -Up
U - Indicates the compound was analyzed for, but not detected.
Acid preservation may not be appropriate for 2 Chloroethylvinyl ether.
A separate vial preserved to a pH of 4-5 is recommended in SW846 Chapter 4 for the analysis 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
PASI-I Pace Analytical Services - Indianapolis
SAMPLE QUALIFIERS
Sample: 92442796001
[1] The samples were received outside of required temperature range. Analysis was completed upon client approval.
Sample: 92442796002
[1] The samples were received outside of required temperature range. Analysis was completed upon client approval.
Sample: 92442796003
[1 ] The samples were received outside of required temperature range. Analysis was completed upon client approval.
ANALYTE QUALIFIERS
D6 The precision between the sample and sample duplicate exceeded laboratory control limits.
R1 RPD value was outside control limits.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 09/05/2019 12:30 AM without the written consent of Pace Analytical Services, LLC. Pagel 1 of 15

aceAnalytical`
xwxtpawiabs.can
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project:
Pace Project No.:
M&M Motor Company
92442796
Analytical
Lab ID
Sample ID
QC Batch Method
QC Batch
Analytical Method
Batch
92442796001
Outfall No.1
EPA 1664B
495072
92442796002
Outfall No.2
EPA 1664B
495072
92442796003
Outfall No.3
EPA 1664B
495072
92442796001
Outfall No.1
EPA 8015 Alcohol -Glycol
518926
92442796002
Outfall No.2
EPA 8015 Alcohol -Glycol
518926
92442796003
Outfall No.3
EPA 8015 Alcohol -Glycol
518926
92442796001
Outfall No.1
EPA 3010A
495754
EPA 6010D
495804
92442796002
Outfall No.2
EPA 3010A
495754
EPA 6010D
495804
92442796003
Outfall No.3
EPA 3010A
495754
EPA6010D
495804
92442796001
Outfall No.1
SM 2540D-2011
495128
92442796002
Outfall No.2
SM 254OD-2011
495128
92442796003
Outfall No.3
SM 254OD-2011
495128
Date: 09/05/2019 12:30 AM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 12 of 15

Document Name:
Document Revised: February 7, 2018
_ s�CBAlh31ylIC8�
Sample Condition Upon Recei t SCUR
Page 1 of 2
Document No.:
Issuing Authority:
F•CAR•CS•033•Rev.06
Pace Carolinas Qualit Office
Laboratory receiving samples: �--�/
Asheville ❑ Eden[:]Greenwood ❑ Huntersville L� Raleigh❑ Mechanicsville❑
•I Client Name: Project a: WO# : 92442796
d Ex LJUSPS t �� II I II 119111� II I II III
Courier: Q ad Ea ❑UPS ❑LISPS ❑Client
❑ Commercial ❑Pace ❑Other:_ 92442796
/
Custody Seel Present? ❑Yes No Seals Intact? ❑❑ LYes No C/yr(' —/,�
Date/Initials Person Examiningcontents:.��✓ 46 lq'
Packing Material: []Bubble Wrap 36,bble Bags []None ❑ Other Biological Tissue Wizen?
Thermometer � []Yes ❑No RN/A
RGunlo: 92TO48. Type of ice: Rjwet ❑Blue ❑None
L�
Cooler Temp ('C): 17 . Y Correction Factor: Add/Subtract I-C) 0.0
Books Ten ip Co.I ected lie). Temp117 be above freezing to 6•C
NSPu es out of temp criteria. Samples an ice, tooling process
hasbegun
USDA Regulated Soil ( N/A, water sample)
Did samples o,-riginn to in a quarantine zone within the United Stales: CA, NY, or SC (check maps)? Ditl samples originate from a foreign source (internationally,
❑Yes L o rrXX
Comment s/Discrepancy:
Chain of Custody Present?
es
J3NO
❑N/A
1.
Samples Arrived within Hold Time?
es
ONO
❑N/A
2.
Short Hold Time Analysis 472 hr.)?
Elves
No
EINIA
3.
Rush Turn Around Time Requested?
❑Yes
nd,
❑N/A
4.
Sufficient Volume?
yes
No
N/A
S.
Correct Containers Used?
-Pace Containers Used?
rr!�yye�e$
12K$
[]No❑N/A
ONO
N A
6.
Containers Intact?
t_yyes
No
N A
7.
Dissolved analysis: Samples Field Filtered?
❑v
ON.
N/A
a.
Sample Labels Match COC?
-Includes Dale/Time/ID/Analysis Matrix:
es
of
[]No
❑N/A
_
9.
Heads ace In VOA Vials (a5-6mrn)?
Trip Blank Present?
Trip Blank Custody Seals Present?
Yes
❑Yes
ves
ONO
❑No
No
ONLA
© /A
/A
loVt a /.
11.
COMMENTS/SAMPLE DISCREPANCY
Person contacted: l i11.6 1 1I L) ff y!- Date/Time:
Project Manager SCURF Review: yl a
Project Manager SRF Review: I(��
_ c
Field Data Required? Dyes ONO
11
Date: 0 '� 71
Date:
Page 13 of 15

Document Name:
Document Revised: February 7, 2018
aceMalydral„
Sample Condition Upon Recel t(SCUR)
Page 1 of 2
Document No.:
Issuing Authority:
F-CAR-CS-033-Rev.06
Pace Carolinas Quality Office
'Check mark top half of box If pH and/or dechlorination Is
verified and within the acceptance range for preservation
samples.
Exceptions: VOA, Coliforrrt, TOC, Oil and Grease, DRO/8015 (water) DOC, LLHg
"Bottom half of box Is to list number of bottle
Project If W®# : 92442796
PM: TIH Due Date: 09/05/19
CLIENT: 92—MID QTLAN
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pH Adjustment Log for Preserved Samples
Sample ID
Type of Preservative
pH upon receipt
Date preservation adjusted
Time preservation
adjusted
Amount of Preservative
added
Lot d
Note: Whenever there is a discrepancy affecting North Carolina compliance samples, a copy of this form will be sent to the North Carolina DEHNR Certification Office (i.e.
Out of hold, incorrect preservative, out of temp, incorrect containers.
Page 14 of 15

%5 y,G CHAIN -OF -CUSTODY / Analytical Reque t Document
The Chain -of -Custody is a LEGAL DOCUMENT. All relevant fief is must be completed accurately.
- - - -..""' 2 Seelmn C
Requlred Client Information: Requimd Protect Information: Invoice Information:
Page ' 1 Of 1
Company: Mid Alli nlic Associales, foe.
Report To: H.1f.n. Chmc
Al:ereon:
Address: 409 R000 V.e Cl
Copy To:
Company Name:
Raleinh. NC 27610
Address:
Email:
Purchase Order>:
Pace Duero.
Re ulat0 Aocnc
Prone: Fa Project
ReGwsIM Due Dale:
Name: WM Mole, Company. Inc.
Pam Project Manapec tyrick.hmks(dpemlabsmm
- StateI Location
Project
N:
Pace Profile o; 5921
NC
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