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HomeMy WebLinkAboutNCG210111_MONITORING INFO_20191107V v ,SR D STORMWATER DIVISION CODING SHEET NCG PERMITS PERMIT NO. DOC TYPE ❑ HISTORICAL FILE 4MONITORING REPORTS DOC DATE ❑ b I l l I D 7 YYYYMM DD Semi-annual Stormwater Discharge Monitoring Report Us,:-o for North Carolina DEMLR General Permit No. NCG210000 Date submitted _31/1/19 CERTIFICATE OF COVERAGE No. NCG210111 SAMPLE COLLECTION YEAR —2019 FACILITY NAME Blue Ridge Fiberboard SAMPLE PERIOD ❑ Jan -June ® July -Dec COUNTY Caswell or ❑ Monthly' (month) PERSON COLLECTING SAMPLES Christie Kueneman DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA LABORATORYPACE Lab Cert. # _633 RECEIVED ❑Zero -flow ®Water Supply [:]SA Comments on sample collection or analysis: ❑Other NOV 0 7 2019 PLEASE REMEMBER TO SIGN ON THE REVERSE 4 CENTRAL FILES Part A: Stormwater Benchmarks and Monitoring Results (Monitoring1W?c u1fq' �ly if the facility stores exposed accumulations of sawdust, wood chips, bark, mulch, or other similar material on site for longer than seven (7) days.) No discharge this periodj' Outfall No. - Date Sample Collected` _ (md/dd/yr) _ - 24-hour rainfall . amount, Inch'es3 Chemical Oxygen Demand Total Suspended Solids. Benchmaiks-===> - - 120 mg/L. 100 mg/L or 50 mgjO NC001 10/17/19 .84 102 mg/L 2_9 mg/L N0002 10/17/19 .84 97.6 mg/L _ 7.4 Mg/L 1 Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall. 'For sampling periods with no discharge at any single outf311, you must still submit this discharge monitoring report with a checkmark here. 'The total precipitation must be recorded using data from an on -site rain gauge. Unattended sites may be eligible for a waiver of the rain gauge requirement. 4 See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies. Note: Results must be reported in numerical format. For example, do not report Below Detection Limit, BDL, <PQL, Non -detect, ND, or other similar non - numerical format. When results are below the applicable limits, they must be reported in the format, "<XX mg/L" where XX is the numerical value of the detection limit, reporting limit, etc. in mg/L. Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text. Permit Date: 8/1/2013-7/31/2018 SWU 2145, last revised 7/31/2013 Page 1 of 2 Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month. ❑ No discharge this period?' Outfall No. " Date Sample: "Collected)`amount, (mo/dd/yr): 24-hour rainfalG . ,. Inches3" ...: Non -polar O&G by EPA .1664 (SGT-HEM) N - - Total Suspended ended Solids ' '. , . .:-..:..,: Benchmarks ===>, ;.... 15mg/L- ". 100mg/Lor50mg/L° "Footnotes from Part A also apply to this Part B Note: 1f you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text. FOR PART A AND PART B MONITORING RESULTS: _• A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B. _. '2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART It 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 DEMLR 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 lab results for at end of monitoring period in the case of "No Discharge" reports/ to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: "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." me%eIg U.eeal 11/1/2019 (Signature of Permittee) (Date) Permit Date: 8/1/2013-7/31/2018 SWU-245, last revised 7/31/2013 Page 2 of 2 aceAnalytical e ' wxw.pacelaba.c'onr October 25, 2019 David Gillespie 250 Celotex Way Danville, VA 24541 RE: Project: TSS/COD/PH Pace Project No.: 92450258 Dear David Gillespie: Pace Analytical Services, LLC 205 East Meadow Road - Suite Eden, NC 27286 (336)623-6921 Enclosed are the analytical results for sample(s) received by the laboratory on October 18, 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, °9 —=ZV- Clayton McCrickard clayton.mocrickard@pacelabs.com (336)623-8921 Project Manager Enclosures cc: Christina Kueneman, Blue Ridge Fiberboard Regina Raines, Blue Ridge Fiberboard MIKE VEIHL, Blue Ridge Fiberboard Mike Veihl, Blue Ridge Fiberboard Tammy Yeatts, Blue Ridge Fiberboard REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, without the written consent of Pace Analytical Services, -LC. Page 1 of 11 ace Analytical w wpecalabs.cwe Project: TSS/COD/PH Pace Project No.: 92450258 Pace Analytical Services, LLC 205 East Meadow Road - Suite A Eden, NC 27288 (336)623-8921 Asheville Certification IDs 2225 Riverside Drive, Asheville, NC 28804 Florida/NELAP Certification #: E87648 Massachusetts Certification #: M-NC030 North Carolina Drinking Water Certification #: 37712 Eden Certification IDs 205 East Meadow Road Suite A, Eden, NC 27288 North Carolina Drinking Water Certification #: 37738 CERTIFICATIONS North Carolina Wastewater Certification #: 40 South Carolina Certification #: 99030001 Virginia[VELAP Certification #: 460222 North Carolina Wastewater Certification #: 633 Virginia/VELAP Certification #: 460025 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 11 aceAnalytical e wwwpaceleW.can SAMPLE ANALYTE COUNT Project: TSS/COD/PH Pace Project No.: 92450258 Pace Analytical Services, LLC 205 East Meadow Road - Suite Eden, NC 27288 (336)623-8921 Lab ID Sample ID Method Analysts Analyte5 Reported Laboratory 92450258001 OUTFALL 001 SM 2540D-2011 NMH 1 PAASI-E EPA 9040C MWF 1 PASI-E SM 5220D-2011 GC 1 PASI-A 92450258002 OUTFALL 002 SM 254OD-2011 NMH 1 PASI-E EPA 9040C MWF 1 PASI-E SM 5220D-2011 GC 1 PASI-A REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, without the written consent of Pace Analytical Services, -LC. Page 3 of 11 Pace Analytical Services, LLC aceAnalytica/ a 205 East Meadow Road - Suite A Eden, NC 27288 t vpzoalebs.ccn (336)623-6921 ANALYTICAL RESULTS Project: TSS/COD/PH Pace Project No.: 92450258 Sample: OUTFALL 001 Lab ID: 92450258001 Collected: 10/16/19 13:40 Received: 10/18/19 11:15 Matrix: Water Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual 2540D TSS, Low -Level, Eden Analytical Method: SM 254OD-2011 Total Suspended Solids 239 mg/L 7.1 1 10/22/19 13:28 9040 pH Analytical Method: EPA 9040C pH at 25 Degrees C 6.6 Sid. Units 0.10 1 10/18/19 15:10 H3 5220D COD Analytical Method: SM 5220D-2011 Preparation Method: SM 5220D-2011 Chemical Oxygen Demand 102 mg/L 25.0 1 10/24/19 16:13 10/24/19 22:21 Sample: OUTFALL 002 Lab ID: 92450258002 Collected: 10/16/19 14:10 Received: 10118/19 11:15 Matrix: Water Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual 2540D TSS, Low -Level, Eden Analytical Method: SM 2540D-2011 Total Suspended Solids 7.4 mg/L 2.0 1 10/22/19 13:31 9040 pH Analytical Method: EPA 9040C pH at 25 Degrees C 6.6 Std. Units 0.10 1 10/18/19 15:19 H3 5220D COD Analytical Method: SM 5220D-2011 Preparation Method: SM 5220D-2011 Chemical Oxygen Demand 97.6 mg/L 25.0 1 10/24/19 16:13 10/24/19 22:22 REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 10/25/2019 02:58 PM without the written consent of Pace Analytical Services, L-C. Page 4 of 11 aceAnalytical vnmpeadabs.even QUALITY CONTROL DATA Project: TSS/COD/PH Pace Project No.: 92450258 Pace Analytical Services, LLC 205 East Meadow Road - Suite A Eden, NC 27288 (336)623-8921 OC Batch: 504701 Analysis Method: SM 254OD-2011 QC Batch Method: SM 2540D-2011 Analysis Description: 2540D TEE, Low Level, Eden Associated Lab Samples: 92450258001, 92450258002 METHOD BLANK: 2712099 Matrix: Water Associated Lab Samples: 92450258001, 92450258002 Blank Reporting Parameter Units Result Limit Analyzed Qualifiers Total Suspended Solids mg/L ND 1.0 10/25/19 10:32 LABORATORY CONTROL SAMPLE: 2712100 Spike LCS LCS %Rae Parameter Units Cone. Result %Rec Limits Qualifiers Total Suspended Solids mg/L 250 256 102 90-110 SAMPLE DUPLICATE: 2712101 92450258001 Dup Parameter Units Result Result RPD Qualifiers Total Suspended Solids mg/L 239 239 0 SAMPLE DUPLICATE: 2713651 92450258002 Dup Parameter Units Result Result RPD Qualifiers Total Suspended Solids mg/L 7.4 7.6 3 Results presented on this page are In Ne units Indicated by ttle'Units" column except where an alternate un It Is presented to Me right of die result. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 10125/2019 02:58 PM without the written consent of Pace Analytical Services, L-C. Page 5 of 11 aceAnalytical www.paceleas.wm QUALITY CONTROL DATA Project: TSSICOD/PH Pace Project No.: 92450258 QC Batch: 504706 Analysis Method: EPA 9040C QC Balch Method: EPA 9040C Analysis Description: 9040 pH EDEN Associated Lab Samples: 92450258001, 92450258002 SAMPLE DUPLICATE: 2712109 92450224001 Dup Parameter Units Result Result RPD Qualifiers pH at 25 Degrees C Sid. Units 7.3 7.3 0 H3 Pace Analytical Services, LLC 205 East Meadow Road - Suite A Eden, NC 27288 (336)623-8921 Results presented on this page are In the units Indicated by the "Units" column except whore 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: 10/25/2019 02:58 PM without the written consent of Pace Analytical Services, LLC. j Page 6 of 11 aceAnalytical a wwnpace/abs.uom QUALITY CONTROL DATA Project: TSS/COD/PH Pace Project No.: 92450258 OC Batch: 505622 Analysis Method: SM 5220D-2011 QC Batch Method: SM 5220D-2011 Analysis Description: 5220D COD Associated Lab Samples: 92450258001, 92450258002 METHOD BLANK: 2716326 Matrix: Water Associated Lab Samples: 92450258001, 92450258002 Blank Reporting Parameter Units Result Limit Analyzed Qualifiers Chemical Oxygen Demand mg/L NO 25.0 10124/1922:17 Pace Analytical Services, LLC 205 East Meadow Road - Suite Eden, NC 27288 (336)623-8921 LABORATORY CONTROL SAMPLE: 2716327 Spike LCS LCS %Rec Parameter Units Conc. Result % Rec Limits Qualifiers Chemical Oxygen Demand mg/L 750 776 104 90-110 MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2716328 2716329 MS MSD 92450094003 Spike Spike MS MSD MS MSD %Rec Parameter Units Result Conc. Conc. Result Result %Rec e/ Rec Limits RPD Qual Chemical Oxygen Demand mg/L 25.2 100 100 130 130 105 105 90-110 0 MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2716330 2716331 MS MSD 92450558001 Spike Spike MS MSD MS MSD e/ Rec Parameter Units Result Conc. Conc. Result Result %Rec %Rec Limits RPD Qual Chemical Oxygen Demand mg/L 2840 100 100 2910 2920 75 84 90-110 0 M1 Results presented on Vale page are In the units Indicated by Me'Units' column except where an alternate un It Is presented to the right of the result. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 10/25/2019 02:58 PM without the written consent of Pace Analytical Services, LLC. Page 7 of 11 laceAnalyfical* ..pawl2cs.corn QUALIFIERS Project: TSS/COD/PH Pace Project No.: 92450258 DEFINITIONS DF - Dilution Factor, if reported, represents the factor applied to the reported data due to dilution of the sample aliquot. NO - 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. POL - Practical Quantitation Limit. Pace Analytical Services, LLC 205 East Meadow Road - Suite A Eden, NC 27288 (336)623-8921 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 analyle 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 analyle is a combined concentration. Pace Analytical is TNI accredited. Contact your Pace PM for the current list of accredited analyses. TNI -The NELAC Institute. LABORATORIES PASI-A Pace Analytical Services -Asheville PASI-E Pace Analytical Services - Eden ANALYTE QUALIFIERS H3 Sample was received or analysis requested beyond the recognized method holding time. M1 Matrix spike recovery exceeded OC limits. Batch accepted based on laboratory control sample (LCS) recovery. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 10/25/2019 02:58 PM without the written consent of Pace Analytical Services, LLC. Page 8 of 11 (�ace Analytical"' wm¢pacala6d.com QUALITY CONTROL DATA CROSS REFERENCE TABLE Pace Analytical Services, LLC 205 East Meadow Road - Suite Eden, NC 27288 (336)623-8921 Project: Pace Project No.: TSS/COD/PH 92450258 Analytical . Lab ID Sample ID QC Batch Method QC Batch Analytical Method Batch 92450258001 OUTFALL 001 SM 2540D-2011 504701 92450258002 OUTFALL002 SM 25400-2011 504701 92450258001 OUTFALL 001 EPA 9040C 504706 92450258002 OUTFALL002 EPA 9040C 504706 92450258001 OUTFALL001 SM 5220D-2011 505622 SM 5220D-2011 505675 92450258002 OUTFALL002 SM 5220D-2011 505622 SM 5220D-2011 505675 Date: 10/25/2019 02:58 PM REPORT OF LABORATORY ANALYSIS This report shall not he reproduced, except in full, without the written consent of Pace Analytical Services, LLC. Page 9 of 11 CHAIN -OF -CUSTODY Analytical Request, Document LAB USE ONLY Affix Workorder to ! e iAiti�' ` PaceAnalytical' .7Z�4�5®Zy}58f x e. t ctAP +'es"'g y""MTII'L4 $•tut p ttAsz' aL '-^'i� 'Cxd`Swk �x'Y'-u`. aE a a y Chain-of-Custodyis a LEGAL DOCUMENT - Comle[e all relevant fields r ,r 5 + L IgIp�g�gI'g.yI'gIgI,Iz'III II! II II �IIta iCra„ k�'iv7e'`Q,s'ti- T h✓roi n:Company: Billing Informatio e' ALLS,-HA' DEDi A.ryRVi.�`Fy9x x .a - J Container Preservative Type x„ Address: Report To: Email To: •- preservative Types (1) nitric acid, (2) sulfuric and, (3) hydrochloric acid (<) socilu n hydroxide, (5) zinc acetate, (6) methanol, ry) sodium bisulfate, (8) sodium thlosulfrte, (9) hexane, (A) ascorbic Wd, 13) ammonium sulfate, IClammanlum hydroxide, fDI TSP:(U{Unprpserved, 10) Other Copy To: - Si to Collection In fo/Address: Analyses Lab'.Ppabfe/Line - t n.' Customer Project Name/Number: Stater County/City: Time Zone Collected y4 i- - LaL Semple Aece Checklis / IIPTI IMTI I CT[ I ET pc J -� v } " .- t 1. r e > ,>, Cuseody sealsPreae t/i tact Y N M1��': cuveod Tsignetu eatPra ent 'f'Y N Hrcp, Phone: - Site/Facility ID H: Compliance Monitoring? Email: I'I Yes [ I NO ,L�, Signature;Present /1 I NA j t sc[ori AOCtlee Intact�b d�N NA .lh cdrre [Dories mow" /h NAg.I Collected By (print): Purchase Order tt: DW PWSID 'r, 'l. .9 LL QOO[e q: DWLOCation Code: -. L�• y ''� ill -. r {� - •� ��y.d SUEfic a t, Volume ,ry Z NA S90plea ABce1VCd O 1I .y, N !A I„. F 'yppi H dspaCe TCceptaElC jY1N jYI " Collected By si ndINI Y( B around Date. Required: Imme late Pdc a Un l[C °'ry Y a, a ..USDA Regulated soils "'�-v;, Y N NIA, I I yes I )No ." '.!,�. �• + '. y a 'j' camPles in FSd d 9 T11not-^L,1"'N 1A/ Frosani:t x 0 t+A -- Sample isposa Rush: - - Field Filtered (i(applicable) }pRes i I Dispose as appropriate ( I Return [ )Same Day [ j Next Day ( J Yes I ]No,A Y - ,c1,5 r p IAchFie: 12 Day (, 13 Day [ j4Ddy 15Uay Analysis: toI pH I"NNFrM1 clte 7,e / sFj(�xjW/'•/ IHold: Chargs APplyl t 45,(Expedite b. f{ ..{ -'atnple' pH S raPv � SULf de Pce e [ RYY raa Ace tatescrnpsta? lrfti Matrix Codes (Insert in Matrix box below): Drinking Water (DW),.Ground Water(GW), WastewaterWW), Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor IVh Other (OTI. ,•. ka 5 , f 's v G r LA ��serotarx f ahb sample N `/ cavmenas h A, Comp / Collected (or Res a of Customer Sample ID P Matrix' Grab Composite Start) Composite End CI Ctns .x,x .^ :-» it �•y �, nE 5 i ..^ as tv V •F},C Date Time Date Time csr� f{x'r•., nY.c't' ,1, a , 'S'.�i1- �T49tLW r..I. li M IT _ Ir Lt] .li N l: 1G F !{%•� f _c t » b iH.� ,n s ' r}i � i -'. Agi^�t w ? .S�il _. 'it j' T ..0 .. (�•. h�' V4 �` Y � L G'.4' ft � '�:• ..fi.( .� Fi.+^F L .Y, lY�'abN-f«.. iG"I s-« ,�y �m •xJ ��... Y re. �..1 .> N F 1 .r. �� vk •} Ja i.11 tij.ei�p< nrrn . 4�' JF hL. !.?. *"".x jt� �.i, i'. Customer Remarks/Spacial Conditions/ Possible 1-1a2ards: Type o(iceLsed e[ y:TBlue. Dryh, xa�None�x-a+'�utj` SHORT nOL05PRESENT (<72 hours) .. p;P {z",iY -rr tab Sample Temperature Info "i` , yt Temp Blank Recervetl n•.Y P c.;ing Ma axiaW —11 l.sed ., '� 'TV s;y + au Lab r-ackingtl,.•t* "$[' .;�. d jZ� e",'4�4� U!O-�G U✓c9 } v,ICDoI r.l, emp Upon':Racalpt �oC ymCorr �Fattor 'u/oC T+Cooler 1 Corrected Temo �o Radchem zampl (sl screenedx[<5f10 cpml Y� N NAz>n '. r•c , t <dmples reseedCoolerjlsThe k"FEDEXy-+..UPS,; Client;Course;.- Pac urger y<,trj Relinquished by/Company: (Signature) Date/Time. .� b Received by/ mean ignat Daternme ay.:y MTIL'LAB USE ONLY 'S-'z"" i Y C„o3mwments kr,,.S `a G -eti $ Ioll7/19 Table q.-wt a r.v F R n tl byrCo a. (Signatur _ _ Date/Time: }' J R :(Signature) Date/Time. Acctnum y Taa L y w r= t 'S Template y' M n 81anit Received kAy#` Ns :aW L7 C /C 7f,'i% Yc i. , x �a ..I .{Tnp _ al N R nquishe y Company: (Signature) Recerved /Coin any:(Si nature) Date Time: Non COn(Oflndn[e(5)� Page. y 5 ti sk'91 CHAIN -OF -CUSTODY -Analytical Request,,Document z' AS USE ONLY AfFlx Wo ko der(Lolti i Y Chain of Custody is a LEGAL DOCUMENT- Complete all relevent fields Company - -; E � Billing Information: •� .P t h, T t 'tS -'d CLI g $ LL ASHADED ARl, a I 4,vp$ Address:` J V gContamn 11reservatrv, T'pe"' •` ReportTo: - Email To: - .. •'Preservative Types (z)nitric acid.(2) sulfuric acid.(3) hydrochlt • (6)-.etharol, IT soduir bs 3te' 121 sodium thiosutfate.(^+P hiES 'Copy To: !..'�� _ Site Collectidn Info/Address: / - m (C) amonium, hydmnide;(D) 5P: (U) Unpreserved, (0) other 1 - F Customer ProjeR Name/Number:. State:Counry/City: Time Zone Collected:,Analyses'I "?y �_.+ 4 I:dpTi IMTI ICT (.JET ;' Phone: ;" '• - Site/Facillty ID k _' - Compliance Monitoring? .. z i mail:. �•._. .,. _ �: I I Yes �,I INo' ;,. ••L e� t 1 K Y _ Tt Collected ,ffBy(pt`int): Purchase Orderfl� Quote kn' OW PWS ID k: '^• xs k '1 C`kC.�oQrit.•i^ - _. - DW Location Code; -' • Collected By,(sign a[ur I: m Tuarc and Date Required. Imme late y Pac a on Ice I.]Yez_ I SamplelDisposali ( I Dispose as appropriate l Remrd flush: - ,- I-1Same Day I1Next Day' Field Filtered (if applicahie) -'I -n -� `•YSy.#i 1. I(Yes INo:, �'' e r,3 jrr, f I Arch,ve: I I Hold: .. I 1 2'Day .1 13 Day I 14 Day I .1 5 Day - _ Analysis: "i • #t . .. IE pedlte Chamcs APPIYI jy 'Ma ix Codes (Insert in Matrix hoe below); Dnnking Water(DW),Ground Wa[ec.(GW), Wastewater(WW), '��``+• z: i Product (P), Soil/Solid.(SLJ, Oil (OL), Wlpe (WP), Alr (AR); Tissue ITS), Bioassay (B), Vapor (V); Other (Oi) Comp/ Collected (c - - Composite End :Res p of >+r•• `Jt '4 ��°' > ' jyxfi l Customer Sample ID Maui COmpO51IP $fart) [ Ctns j. +W... ..+ bs. Date I ;Time Date Time- tlt`G%f'1:..�r{fit 'TS.. y5arc I 04) 4 OF oCi. 'I -�'v •, 1(9 ICR/�t `} -i ;{'n � i r.i iy �,rp $P., v ;< � .. a..•z wee:: 1cr' ,. s. e_ s...+. j Customer Remarks / Special Conditipns / Possible Haza, i 11417/ M®® s�®svoe�s Received by/Comps y(SignatWe`) 7 ""'f�}J g yl,Q iWA o, la)a mwlgte, '� 11