HomeMy WebLinkAboutNCG100024_MONITORING INFO_20190610STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCG �d�bay
DOC TYPE
❑ HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑
YYYYMMDD
Mid Atlantic
Engineering & Environmental Solutioro
July 23, 2019
NCDEQ/DWR
Attention: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Subject: STORMWATER SAMPLING RESULTS
FOSS AUTO RECYCLING
1915 RIDDLE ROAD
DURHAM, DURHAM COUNTY, NORTH CAROLINA
PERMIT NCGl00024
MID -ATLANTIC JOB NO. OOOR2066.00
To Whom It May Concern:
409 Rogan View Court
Raleigh, NC 27610
*Me* 919,250.491 a
facsimile 919,250,9950
MAAONLINEXCIM
Attached please find the Stormwater Discharge Monitoring Report (DMR) and analytical
report for the sampling conducted at the above -referenced site. A stormwater sample was
collected on June 10, 2019 and analyzed for total suspended solids (TSS), pH, total
recoverable lead, oil and grease and ethylene glycol. As indicated on the attached DMR,
all parameters were below their respective benchmark values or within their benchmark
range. If you have any questions or need additional information, please contact me at
919-250-9918
Sincerely,
MID -ATLANTIC ASSOCIATES, INC.
Ron J. Davis ^CNOV 21013
Stormwater Services Manager DWR E�Tp S
jv
Attachments: Stormwater Discharge Monitoring Report
Laboratory Analytical Report
EXPERIENCED CUSTOMER FOCUSED INNOVATIVE
STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
CERTIFICATE OF COVERAGE NO. NCG100024 SAMPLES COLLECTED DURING CALENDAR YEAR: 2019
FACILITY NAME Foss Recycling, Inc., Durham, NC COUNTY Durham
PERSON COLLECTING SAMPLE(S) Anthony Smith PHONE NO.(8001 672-9722
CERTIFIED LABORATORY(S) Pace Analytical Lab #12
Lab # PLEASE REMEMBER TO SIGN ON THE REVERSE 4
Part A: Stormwater Benchmarks and Monitoring Results
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
06/10/19
4.0
7.9
6.3
<4.8
<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 Tier 2 responses in the General
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), 1
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. 1 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 properl ather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons ' ctly responsibl gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
am aware th ere are sig ' is t pen ' s for submitting false information, including the possibility of fines and imprisonment for knowing violations."
V/
(Signature pf'Permittee or Designee) (Dat
Form SWU-251, last revised October25, 2012
Page 2 of 2
aceAnalytical
e ..pacelaba,cvrn
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704)875-9092
June 21, 2019
Chuck Hoffman
Mid -Atlantic Associates, Inc
409 Rogers View Court
Raleigh, NC 27610
RE: Project: Foss Recycling -Durham
Pace Project No.: 92432460
Dear Chuck Hoffman:
Enclosed are the analytical results for sample(s) received by the laboratory on June 11, 2019. The
results relate only to the samples included in this report. Results reported herein conform to the most
current, applicable TNI/NELAC standards and the laboratory's Quality Assurance Manual, where
applicable, unless otherwise noted in the body of the report.
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
Tyriek Hooks
tyriek.hooks@pacelabs.com
(704)875-9092
Project Manager
Enclosures
cc: Ron Davis, Mid Atlantic Associatees, Inc.
pp "CC
'60
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REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 1 of 13
aceAnalytical
~..peceleb&=
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704)875-9092
Project: Foss Recycling -Durham
Pace Project No.: 92432460
Indiana Certification IDs
7726 Moller Road, Indianapolis, IN 46268
Illinois Certification #: 200074
Indiana Certification #: C-49-06
Kansas/NELAP Certification M E-10177
Kentucky UST Certification M 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 M 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 Drinkina Water Certification #: 37712
CERTIFICATIONS
Ohio VAP Certification M CL0065
Oklahoma Certification #: 2018-101
Texas Certification #: T104704355
West Virginia Certification #: 330
Wisconsin Certification M 999788130
USDA Soil Permit* P330-16-00257
South Carolina Certification #: 99006001
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
VirginiafVELAP Certification M 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
Virginia/VELAP Certification #: 460222
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except In full,
without the written consent of Pace Analytical Services, U.C. Page 2 of 13
19/
aceAnalytical`
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Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704)875-9092
SAMPLE ANALYTE COUNT
Project:
Pace Project No.:
Foss Recyding-Durham
92432460
Analytts
Lab ID
Sample ID
Method
Analysts
Reported
Laboratory
92432460001
Outfall 1
EPA 1664E
JMS
1
PASI-C
EPA8015AIcohol-Glycol
CPH
1
PASI-I
EPA6010D
SH1
1
PASI-A
SM 254OD-2011
MJP
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 13
aceAnalytical
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Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704)875-9092
ANALYTICAL RESULTS
Project: Foss Recycling -Durham
Pace Project No.: 92432460
Sample: Outfall 1 Lab ID: 92432460001 Collected: 06/10/19 07:45 Received: 06/11/19 09:38 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 4.8 1 06/20/19 07:29
8015M Glycols in water Analytical Method: EPA 8015 Alcohol -Glycol
Ethylene glycol ND mg/L 5.0 1 06/19/19 01:52 107-21-1
6010 MET ICP Analytical Method: EPA 601 OD Preparation Method: EPA 3010A
Lead ND ug/L 5.0 1 06/19/19 23:21 06/21/19 02:45 7439-92-1
2540D Total Suspended Solids Analytical Method: SM 2540D-2011
Total Suspended Solids 6.3 mg/L 4.2 1 06/14/19 14:35
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 06/21/2019 04:21 PM without the written consent of Pace Analytical Services, LLC. Page 4 of 13
aceAnalytical
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Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Hunlersville, NC 28078
(704)875-9092
QUALITY CONTROL DATA
Project:
Foss Recycling -Durham
Pace Project No.:
92432460
OC Batch:
482237 Analysis Method: EPA 1664E
QC Batch Method:
EPA 16648 Analysis Description: 1664 SGT-HEM, TPH
Associated Lab Samples: 92432460001
METHOD BLANK: 2607690
Associated Lab Samples: 92432460001
Parameter Units
Total Petroleum Hydrocarbons mg/L
Matrix: Water
Blank Reporting
Result Limit Analyzed Qualifiers
NO 4.8 06/20/19 07:21
LABORATORY CONTROL SAMPLE:
2607691
Spike LCS
LCS
% Rec
Parameter
Units
Conc. Result
% Rec
Limits
Qualifiers
Total Petroleum Hydrocarbons
mg/L
19.2
21.2
110
64-132
MATRIX SPIKE SAMPLE:
2607692
92432460001
Spike
MS
MS
% Rec
Parameter
Units
Result
Conc.
Result
% Rec
Limits Qualifiers
Total Petroleum Hydrocarbons
mg/L
ND
19.2
20.3
102
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,
Date: 06/21/2019 04:21 PM without the written consent of Pace Analytical Services, LLC. Page 5 of 13
aceAnalytical.
www.pttcela6s.crom
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704)875-9092
QUALITY CONTROL DATA
Project: Foss Recycling -Durham
Pace Project No.: 92432460
QC Batch: 507125 Analysis Method: EPA 8015 Alcohol -Glycol
QC Batch Method: EPA 8015 Alcohol -Glycol Analysis Description: EPA 8015 Modified
Associated Lab Samples: 92432460001
METHOD BLANK: 2340100
Associated Lab Samples: 92432460001
Parameter Units
Ethylene glycol mg/L
LABORATORY CONTROL SAMPLE: 2340101
Parameter Units
Ethylene glycol mg/L
Matrix: Water
Blank Reporting
Result Limit Analyzed Qualifiers
ND 5.0 06/18/1917:03
Spike LCS
Conc. Result
25 21.9
LCS % Rec
e/ Rec Limits Qualifiers
87 48-150
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2340102
2340103
MS
MSD
7093905001 Spike
Spike
MS
MSD MS MSD % Rec
Parameter Units Result Conc.
Conc.
Result
Result % Rec % Rec Limits RPD Qual
Ethylene glycol mg/L <5.0 25
25
21.1
21.2 75 76 34-153 1
Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 06/21/2019 04:21 PM without the written consent of Pace Analytical Services, LLC.
Page 6 of 13
aceAnalytical"
awwpswlabs.com
Pace Analytical Services, LLC
9800 Kinsey Ave. Suite 100
Huntersville, NC 28078
(704)875-9092
QUALITY CONTROL DATA
Project: Foss Recycling -Durham
Pace Project No.: 92432460
QC Batch: 482185 Analysis Method: EPA 6010D
QC Batch Method: EPA 3010A Analysis Description: 6010 MET
Associated Lab Samples: 92432460001
METHOD BLANK: 2607536 Matrix: Water
Associated Lab Samples: 92432460001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Lead ug/L ND 5.0 06/21/1902:39
LABORATORY CONTROL SAMPLE: 2607537
Spike LCS LCS e/ Rec
Parameter Units Conc. Result e/ Rec Limits Qualifiers
Lead ug/L 500 484 97 80-120
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2607538
2607539
MS
MSD
92432460001 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
506 490 101
97 75-125 3
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: 06/21/2019 04:21 PM without the written consent of Pace Analytical Services, LLC.
Page 7 of 13
(�IaceAnalytkal
w ..pacelabs.opm
QUALITY CONTROL DATA
Project: Foss Recycling -Durham
Pace Project No.: 92432460
OC Batch: 481182 Analysis Method: SM 254OD-2011
OC Batch Method: SM 254OD-2011 Analysis Description: 2540D Total Suspended Solids
Associated Lab Samples: 92432460001
METHOD BLANK: 2602798
Associated Lab Samples: 92432460001
Parameter Units
Total Suspended Solids mg/L
LABORATORY CONTROL SAMPLE: 2602799
Parameter Units
Total Suspended Solids mg/L
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704)875-9092
Matrix: Water
Blank Reporting
Result Limit Analyzed Qualifiers
ND 2.5 06/14/1914:34
Spike LCS LCS % Rec
Cone. Result e/ Rec Limits Qualifiers
251 246 98 90-110
SAMPLE DUPLICATE: 2602800
92432543001 Dup
Parameter Units Result Result
Total Suspended Solids ni 64.7 62.7
SAMPLE DUPLICATE: 2602801
92432558002 Dup
Parameter Units Result Result
Total Suspended Solids mg/L 36.8 42.0
RPD Qualifiers
3
RPD Qualifiers
13 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,
Date: 06/21/2019 04:21 PM without the written consent of Pace Analytical Services, L-C. Page 8 of 13
aceAnalytical
wivw.pal;eWti.mn
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
(704)075-9092
QUALIFIERS
Project: Foss Recycling -Durham
Pace Project No.: 92432460
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 EPA guidelines, 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
ANALYTE QUALIFIERS
D6 The precision between the sample and sample duplicate exceeded laboratory control limits.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 06/21/2019 04:21 PM without the written consent of Pace Analytical Services, LLC. Page 9 of 13
aceAnalytical
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Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Hunlersville, NC 2BO78
(704)875-9092
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project:
Pace Project No.:
Foss Recycling -Durham
92432460
Analytical
Lab ID
Sample ID
QC Batch Method
QC Batch Analytical Method
Batch
92432460001
Outfall 1
EPA 1664B
482237
92432460001
Outfall 1
EPA 8015 Alcohol -Glycol
507125
92432460001
Outfall1
EPA 3010A
482185 EPA6010D
482221
92432460001
Outfall 1
SM 2540D-2011
481182
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 06/21/2019 04:21 PM without the written consent of Pace Analytical Services, I.I.C. Page 10 of 13
'yTAG6ty tinytruat'
Laboratory receiving samples: /
Asheville ❑ Eden Greenwood ❑ Huntersville Bl Raleigh[] Mechanicsville❑
Client Name: WON.
Project I : 92432460
,/1JaAC VpII II
Courier: (:dfedEx ❑UPS ❑USPS —[]Client Vlull� IV ��I�Q�III�� QI�
❑ Commercial ❑pace / []Other;— gg,ty3L450
Custody Seat Present? ❑Yes ❑No Seals Intact? ❑Yes
Date/Initials Person Examining Contents:
Packing Material:—E]Bubble Wrap— - ubble Bags —❑None 0—Other Blaloglcal Tissue Frozen?
Thesthometa • .MNIJA
IA Gun ID: 9z 8 . TYPe of ice: et ❑Blue ❑None
Cooler Temp ('C): y. Z , Correction Factor: Add/Subtract (-C) 0.0
Cooler Temp Corrected ('C):I ? Temp should be above freezing to 6Y
❑Samples out of temp criteria. Samples an Ice, cooling process
hasbegun
USDA Regulated Sail ; N/A, water sample)
Did samples or' gi to in a quarantine tone within the United States: CA, NY, or SC (check maps)? Did sandes originate from a foreign source (internationally, .
. Yes o IncludagHawali and Puerto Rico)? ❑Yes []NO
Comme?ils/ re anc :
Chain Of Custody Present?
,.. �
Of.
❑No
❑N/A
1. '
Samples Arrived within Hold Time? _
es
[]NO
❑N/A
2.
Short Hdld.Time Analysis (<72 hr.)?
Oyes
No
[]N/A
3,
Rush Turn Around Time Requested?
Oyes
No
❑N/A
4.
Sufficient Volume?
es
No
N/A
S.
Correct Containers Used?
-Pace Containers Used?,
�Yee -
Lf'Yes
*❑Na
[]No
[]N/A
N/A
6.
-
Containers Intact?
ves
❑No
N/A
7.
- Dissolved analysis: Samples Field Filtered?
❑Yer
[]No
N/A
B.
Sample Labels Match COC?
-Includes Da[e/Time/10/Analysis Matrix:
es
❑No
❑N/A
9.
Headspace in VOA Vials (o5-6mm)?
ves
ONO-
❑N/A
10.
Trip Blank Present?
TripBlank Custody Seals Present?
❑Yes
Yes
ago
❑No
,❑N//A
�[_IN/a
11. .
DISCREPANCY
fVO 4
Field Data Required? ❑Yes []NO
Person contacted: Date/Tlme:
--Project Manager SCURF Revlew: -- Date: [/l?6JJ/
Date: �
C Y /�/I
Project Manager SRF Review:
Page 11 of 13
Document No.: Issuing Authority:
( I F-CAR-CS-033-Rev.06 I Pace Carolinas Quality Office
'Cheek mark top half of box If pH and/or dechlorination is Project 1 WI04, : 9►2432460
verified and within the acceptance range for preservation pPl : TIIf Due Date: 06/25/19
samples.
Exceptions: VOA, Conform,roc, Oil and Grease,DRO/8019(water) DOC, LLHg CLI:ENT: 92—MID RTLAN
"Bottom half of box Is to list number of bottle
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pH Adjustment Log for Preserved Samples
Sample ID
Type of Preservative
pH upon recelpt
Date preservation adjusted
Time presemialcn
adjusted
Amount of Preservative
added
lot 0
—77
Note: Wheneverthere 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 12 of 13
11 CHAIN -OF -CUSTODY / Analytical R I�quest
PaeeAna1j4 �epal- The Chain-of-C"IMY is a LEGAL DOCUMENT. All relevant fickis
Ae,Atpacelaed.com
Document
oust be completed accurately.
Section Section 8 Section C K/ JlO
Required Cflew Information: Required Project Information:
CompanYl,A J Invoice Information:
rIIQ C / Report To: ( O AA p Fyn Attention:
AOdnero; �� (� M1
dit bow— COmDanY Na
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Address ' �'
ER Tor Purcha
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Pefere »: coot.Relc
Php ¢ - F i, 0 - Prgem Nam Pam Pray7t
Roquestetl Due DateR T: 1: Project Number ' `Out MvmgO.
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Section D Matrix Codes
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Onnking Water DW
Water WT
Wa5t—zoar lNW
Product P
Shc/Solid SL
SAMPLE ID 011 OL
wipe
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Sample IDs MUST BE UNIQUE Tax. TS
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Requested
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START
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Pace Project No./ Lab I.D.
DATE
TIME
DATE
TIME
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2
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A
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5
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9
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70
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77
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72
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ADDITIONAL COMMENTS
RELINQUISHED BY I AFFILIATION
DATE
TIME
ACCEPTED BY/
FILIATION
GATE
TIME
SAMPLE CONDITIONS
ll
33
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- �1 `)q ORIGINAL SAMPLER NAME AND SIGNATURE
NT N I �/ r `` PRINT Name of SAMPLER:
Vt J
p ys SIGNATURE of SAMPLER:
W 'Impa4ml Note: By 5 Ws formyw wm.u' opting Pepe s NET 00 dry pnyeeenl term: nM nOrcnirxl to L to cM1argnp pl LS•R Oer monlM1 Iw nny imoims Oitl el.in 30 tl
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ATE Signed
I
I
F-ALL-O-020rev.0T. 15-May-2007