NCG030246_MONITORING INFO_20190213

m'N
ST0RMWA7ER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
Iv C&
DOC TYPE
❑HISTORICAL FILE
MONITORING REPORTS
DOC DATEz
()-
YYYYMMDD

CORNING
February 4, 2020
Ahmed Koilakh Hickory Manufacturing and t 828-901-5699
Plant Manager Technology Center f 828-901-5665
1164 A 23r1 St SE Ahmed, [e-mail]
Hickory, NC 28602 www.r-oming.com
North Carolina Department of Environmental Quality
Division of Energy, Mineral, and Land Resources
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Dear Sir/Madam:
Please hind enclosed an original and one (1) copy of the Stormwater Discharge Monitoring
Report for Corning Optical Communications, LLC — Hickory Manufacturing and Technology
Center (HMTC) located in Hickory, Catawba County, North Carolina. The stormwater
samples were collected on 1/2/2020 for the permitted outfalls and represent the monthly
sample as specified in the requirements set forth by NCDEQ.
Additional attachments include the Laboratory Analytical Report, Chain -of -Custody, Rainfall
Record, and Qualitative Monitoring Report. Please contact Steve Street if you have any
questions regarding this submittal at 828-901-6695.
Sincerely, R E C E l \/F D
FEB 13 2019
CENTRAL FILES
Ahmed Koilakh UWR SECTION
Plant Manager
cc: Kim Kelley
Steve Street
© 2020 Corning incorporated. All Rights Reserved.

Stormwater Discharge Monitoring Report
for North Carolina Division of Energy, Mineral and Land Resources General Permit No. NCG030000
Date submitted 1/29/2020
CERTIFICATE OF COVERAGE NO. NCG03 0 2 4 6
FACILITY NAME Hickory Manufacturing and Technology Center
COUNTY Catawba RECEI\/ED
PERSON COLLECTING SAMPLES Steve Street f�
LABORATORY Water Tech Labs Lab Cert. # 50 C ED Za�g
Comments on sample collection or analysis: CEtiTi�AL1l ES
Monthly sample ^WR SEG_rlo ``
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR 2020 - Monthly (Jan)
SAMPLE PERIOD ❑ Jan -June ❑ July -Dec
or E] Monthly' Lmonth
DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA
❑Zero -flow ❑Water Supply ❑SA
*Other C
PLEASE REMEMBER TO SIGN ON PAGES 2 AND/OR 3 -->
❑ No discharge this period?z
Outfall No.
Date Sample
Collected'
(mo/dd/yr)
24-hour rainfall
amount,
Inches3
Total Suspended Solids
pH,
Standard units
Total Copper
Total Lead
Total Zinc
Non -Polar O&G/Total
Total Petroleum
Hydrocarbons
Toxic
Organicss
Benchmarks
-
-
100 mg/L or 50 mg/L°
6.0 — 9.0
0.010 mg/L
0.075 mg/L
0.126 mg/L
15 mg/L
1 mg/L
Parameter Code
-
46529
C0530
00400
01119
01051
01094
00552
78141
SDO 3
112120
.05
6.0
7.71
.013
<.005
.260
<5.6
N/A
SDO 5
1/2/20
.05
4.0
7.77
.009
<.005
.133
<5.6
NIA
' Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
z For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here.
3The 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.
' See General Permit, Section B, Table 1 to identify the especially sensitive receiving water classifications where the more protective benchmark applies.
s Total Toxic Organics sampling is applicable only for those facilities which perform metal finishing operations, manufacture semiconductors, manufacture
electronic crystals, or manufacture cathode ray tubes. For purposes of this permit the definition of Total Toxic Organics is that definition contained in the EPA
Effluent Guidelines for the facility subject to the requirement to sample (for metal finishing use the definition as found in 40 CFR 433.11; for semiconductor
manufacture use the definition as found in 40 CFR 469.12; for electronic crystal manufacture use the definition as found in 40 CFR 469.22; and for cathode ray
tube manufacture use the definition found in 40 CFR 469.31).
Permit Date: 11/1/2018-05/31/2021 SWU-245, last revised 11/1/2018
Page 1 of 3

Facilities that incorporate a solvent management plan into the Stormwater Pollution Prevention Plan may so certify, and the requirement for TTO monitoring
may be waived. 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 electing to employ the TTO monitoring waiver, the discharger shall sign the following 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 the all the provisions of the
solvent management plan included in the Stormwater Pollution Prevention Plan."
Iffn
Name (Print name)
N/A
Title (Print title)
Signature
Date
Note: Results must be reported in numerical format. 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.
Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new oil per month.
❑ No discharge this period?z
Outfall No.
Date Sample Collected'
(mo/dd/yr)
24-hour rainfall amount,
Inches3
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 [ode
-
46529
NCOIL
00552
C0530
Footnotes from Part A also apply to Part B
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: 11/1/2018-05/31/2021 SWU-245, last revised 11/1/2018
Page 2 of 3

FOR PART A AND PART B MONITORING RESULTS:
+ A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS, SEE PERMIT PART If SECTION B.
+ 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B.
• TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES [!] NO
IF YES, HAVE YOU CONTACTED THE DEMI_R REGIONAL OFFICE? YES [H] NO ❑
REGIONAL OFFICE CONTACT NAME: Mr. James Moore and Mr. Zahid Khan
Mail on on inal copy of this DMR including all "No Discharge" reports, within 30 days of receipt of the lab results or of end of monitbring 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.
am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
21 -/ 20 X-0
Signature of Permittee
Date
Permit Date: 11/1/2018-05/31/2021 SWU-245, last revised 11/1/2018
Page 3 of 3

Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling out this f rm, please visit. httn: //nortal.ncdenr.org/webJwg jwsIsu jnpdessw#tab-4
Permit No.: or Certificate of Coverage No.:
Facility Name: Hickory Manufacturing and Technology Center — Corning Optical Communications
County: Catawba Phone No.: 828-901-6695
RECEIVED
Inspector: Steve Street
Date of Inspection: 1 2 2 20
Time of Inspection: 12:35
Total Event Precipitation (inches):.005"
FEB 13 2019
CENTRAL FILES
DWR SECTION
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 outfail. The previous measurable storm event must have been at least 72 hours
prior. The 72-hour storm interval does not apply if the permittee is able to document that a shorter
interval is representative for local storm events during the sampling period, and the permittee
obtains approval from the local DWQ Regional Office.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
(\X\./
1
(Signature of Permittee or Designee)
© 2020 Corning Incorporated. All Rights Reserved,
Pagel of 2
5WU-242, Last modified 10/25/2012

1. Outfall Description:
Outfall No. QQ1 Structure (pipe, ditch, etc.) Pipe
Receiving Stream: Clark's Creek
Describe the industrial activities that occur within the outfall drainage area: Reel storage. solid
waste containers designated for landfill, hazardous waste storagf, and R&D building_
2. Color. Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: Color was clear.
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): No odor was present.
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
0 2 3 4 5
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:
0 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended
solids in the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
W 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes No
8. is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution: Done
List and describe: 500 41 is represented by SDO U.
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.
O 2020 Corning Incorporated. All Rights Reserved.

A f
RUEDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this form, please visit: http;//portal.ncdenr.org/web jwgf ws/su/npdessw#tab-4
Permit No.: or Certificate of Coverage No.:
Facility Name: Hickory Manufacturing and Technology Center — Corning Optical Communications
County: Catawba Phone No.: 828-901-6695
Inspector: Steve Street
Date of Inspection: 1 2 2 2
Time of Inspection: 12.3
Total Event Precipitation (inches):.05"
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 permittee
obtains approval from the local DWQ Regional Office.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
(Signature of Permittee or Designee)
O 2020 Corning Incorporated. All Rights Reserved.
Pagel of 2
SWU-242, Last modified 10/25/2012

1. Outfall Description:
Outfalf No. 002 Structure (pipe, ditch, etc.) Pine
Receiving Stream: Clark's Creek
Describe the industrial activities that occur within the outfall drainage area: Solid waste-containgr$
designated for landfill, metal recycling container, and chemical storage area_(covered).
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: Color was clear.
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): No odor was present.
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
H 2 3 4 5
S. Floating Solids: Choose the number which best describes the amount of floating solids in
the stormwater discharge, where 1 is no solids and 5 is the surface covered with floating solids:
Ol 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended
solids in the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
0 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes No
8. Is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution: None
List and describe: S D #2 is represented by SDO U.
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.
© 2020 Corning Incorporated. All Rights Reserved.

A�A
IWDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling out this form, please visit: http.I/portal.ncdenr.org/web/wqf ws/su/npdessw#tab-4
Permit No.: N/C/ 0/ 3/Q/Q/0/0/0/ or Certificate of Coverage No.:
Facility Name: Hickory Manufacturing and Technology Center - Corning Optical Communications
County: Catawba Phone No.: 828-901-6695
Inspector: Steve Street
Date of Inspection: .11212020
Time of Inspection: 12.31
Total Event Precipitation (inches): Q"
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 permittee
obtains approval from the local DWQ Regional Office.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
(Signature of Permittee or Designee)
© 2020 Corning Incorporated. All Rights Reserved.
Page 1 of 2
SWU-242, Last modified 10/25/2012

1. Outfall Description:
Outfall No. 003 Structure (pipe, ditch, etc.) Pipe
Receiving Stream: Clark's Creek
Describe the industrial activities that occur within the outfall drainage area: Reel storage, machine
shop, n wrh ue.
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: Color was clear.
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): No odor wad present.
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
01 2 3 4 5
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:
n1 2 3 4 5
b. 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? Yes No
B. Is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution: None
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.
O 2020 Corning Incorporated, All Rights Reserved.

I�CDETdR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling out this form, please visit: http;Ilportal.ncdenr.org/web/wil/ws/su/npdessw#tab-I
Permit No.: N// 0//Q/Q/0/Q/0/ or Certificate of Coverage No.:
Facility Name: Hickory Manufacturing and Technology Center — Corning Optical Communications
County: Catawba Phone No.: 828-901-6695
Inspector: Steve Street
Date of Inspection: 11212020
Time of Inspection: 1.2:22
Total Event Precipitation (inches):.05"
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 permittee
obtains approval from the local DWQ Regional Office.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
(Signature of Permittee or Designee)
© 2020 Corning Incorporated. All Rights Reserved.
Page 1 of 2
SWU-242, Last modified 10/25/2012

1. Outfall Description:
Outfall No. 20S Structure (pipe, ditch, etc.) Pipe
Receiving Stream: Clark's Creek
Describe the industrial activities that occur within the outfall drainage area: Manufacture of filer
optic cable and warehouse,
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: Color was clear.
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): No odor was present.
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
q1 2 3 4 5
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:
�1 2 3 4 5
6. Suspended Solids: Choose the number which best describes the amount of suspended
solids in the stormwater discharge, where 1 is no solids and 5 is extremely muddy:
2 3 4 5
7. Is there any foam in the stormwater discharge? Yes No
8. Is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution: None
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.
© 2020 Corning Incorporated. All Rights Reserved.

RAIN GAUGE RECORD
SITE Corning Optical Communications - HMTC
MONTH : January 2020
STORM EVENT DATA
DATE: 1/2/2020
START TIME: 12:05 PM End Time: 12:30 PM
TOTAL TIME: 25 minutes
pH Meter Calibration - Date: 112120 Time: 9:00 am
Temperature: 72F
pH Meter reading for 7.0 buffer solution: 7.00
pH Meter reading for 4.0 buffer solution: 4.01
Slope of the calibration: 95.7%
Buffer expiration date: 2/2021
pH Measured at:
Outfall 003: 7.71
Outfall 005: 7.77
DATE
TIME
RAINFALL INCHES
MEASURED BY
30-Dec
8:00
0
Steve Street
31-Dec
8:00
0
Steve Street
Jan 1st
9:00
0
Steve Street
Jan 2nd
12:00
0
Steve Street
Jan 2nd
13:00
.05"
Steve Street
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

WITERiTECH LRDS.Inc.
, .
POST OFFICE BOX 1056 • #5 PINEWOOD PLAZA DR.
GRANITE FALLS, NORTH CAROLINA 28630
[phone]
SAMPLE: Corning Optical (003) COLLECTION DATE:
1/2/2020
PERMIT #: COLLECTION TIME:
12:31
ADDRESS: Corning Optical RECEIVED DATE:
1/3/2020
P.O. Box 489 RECEIVED TIME:
08:34
Hickory, NC 28603-0489
REPORTED:
1 /23/2020
- ---------
----��
ANALYSIS
ANALYSIS
RESULTS
UNITS
DATE ANALYST
Lead
<0.005
mg/L
119/20
TSS
6.0
mg/L
116/20 irg
Copper
0.013
mg/L
119120
Zinc
0.260
mg/L
119/20
Oil & Grease
<5.6
mg/L
1116/20 idg
®N
LOG ID: 2001-044 REPORTED BY: NC CERTIFIED LAB 4 50
f�6"
"Tony Gragg, Lab Supervisor

f dRTERirrCH LRBS.I.C.
POST OFFICE BOX 1056 • #5 PINEWOOD PLAZA DR.
GRANITE FALLS, NORTH CAROLINA 28630
[phone]
SAMPLE: Corning Optical (005) COLLECTION DATE: 1/2/2020
PERMIT ##: COLLECTION TIME: 12:22
ADDRESS: Corning Optical RECEIVED DATE: 1/3/2020
P.O. Box 489 RECEIVED TIME: 08:34
Hickory, NC 28603-0489
REPORTED: 1 /23/2020
--- - ------ --
- _- - - -
-ANALYSIS--
-- - - - - T.�
ANALYSIS
RESULTS
UNITS -
DATE _ _ ANALYST
Lead
<0.005
mg/L
119120
TSS
4.0
mg/L
116120 irg
Copper
0.009
mglL
119120
Zinc
0.133
mg/L
119120
Oil & Grease
<5.6
mg/L
1116/20 idg
LOG ID: 2001-045 REPORTED BY: NCCERTIFIEDLAB # 50
fol�P 0 i
Tony Gragg, Lab Supervisor

RESEARCh & ANA1YTiCA .
i
For: Water Water Tech Labs, Inc.
P.O. Box 1056
Granite Falls, NC 28630
Attn: Joe Gragg
Report of Analysis
1 /10/2020
.ittttoaIIIgo f
♦�`, C��1 „ ,iop
cc
" ; o? NC #34 Z N
NC #37701
,ten
rfa�lri t n++tti
Client Sample 1D: Corning Disc 003 Lab Sample ID: 76644-01
Site: Water Tech Labs Collection Date: 1/2/2020 12:31
Parameter Method Result Units Rep Limit Analyst Analysis DateJTime
Copper, Total EPA 200.8 0.013 mg/L 0.001 SK 1/9/2020
Lead, Total EPA 200.8 <0.005 mg/L 0.005 SK 1/9/2020
Zinc, Total EPA 200.8 0.260 mg/L 0,01 SK 1/9/2020
Client Sample lD:
Site:
Corning Disc 005
Water Tech Labs
Lab Sample ID:
Collection Date:
76644-02
1/2/2020
12:22
Parameter
Method
Result
Units
Rep Limit Anaivst Analysis DateMme
Copper, Total
EPA 200.8
0.009
mglL
0.001
SK
1/9/2020
Lead, Total
EPA 200.8
<0.005
mg/L
0.005
SK
1/9/2020
Zinc, Total
EPA 200.8
0.133
mg/L
0.01
SK
1/9/2020
l IA = not onalyzed
P.O. Box 473 106 Short Street Kernersville, North Carolina 27284 Tel: [phone] Fax: [phone] www.randalabs.com� Page 1
�2i CU8 ;;BSir, +r1�1

j
�.i ANT Et ;TECIlit
LARS, IfNC)
5 Pinewood Plaza Drive • P.O. Box 1056
Granite Fails, NC 28630
Phone [phone]
CHAIN OF CUSTODY
Ca�/1�n� �1P�t`1C�1 Cor rnknita�+on 5 �M t� Cet�+�,a. * AJCG-630dgto
CLIENT: PERMIT #: kW3066 6
c/o Stve Street
i 16q A a3� st S E
� goo a
Hickory, NC -
PHONE #: [phone]A0 96 /- �s 79S
TYPE SAMPLE: Stormwater
SAMPLER NAME: ¢eve
Sample Collection Information
TYPE
CONTAINERS
ANALYSIS REQUIRED
Sample Location
FacilityName
DATE
TIME
TEMP. °C
Grab/
Composite
No
Plastic/
Glass
Discahr a 003
g
%
l�alaJ
/
Grab
3
TSS, O&G, Lead, Copper,
Zinc
Discahrge 005
I /a f
Grab
3
(�
TSS, O&G, Lead, Copper,
Zinc
elinquished By:
Date:
Time:
Receiv y:
Date:
Time:
d93
Reli quished By:
Date:
Time:
Received B�
c-
Date:
Time:
PRESERVATION:
Cool60C Q'-H�NO3
��l2SO4 j ] Dechlorinating Agent
[ ] NaOH j ] Other
SAMPLE TEMP. @ LAB (°C) I ,b
1 -Chlorine Residuals ', mgll
NC CERTIFIED LAB # 50