NCG030664_MONITORING INFO_20200203

m"w
STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
/v
DOC TYPE
[I HISTORICAL FILE
(A MONITORING REPORTS
DOC DATE
25
p � �a � " D
YYYYMMDD

Southuir' �
February 3, 2020
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Permit No: NCG030000
Certificate of Coverage: NCG030664
Southwire
12331 Commerce Station Drive
Huntersville, NC 28078
Dear Sir/Madam:
FEB U S. 2019
CEti ► MAL FILE:
DWR SECTION
Enclosed is the Semi -Annual Stormwater Discharge Monitoring Report and associated analytical
results for the Southwire Facility.
This report covers required sampling for 2020 January - June Semi -Annual.
Should you have any questions, please contact me at 704-379-9621 or
[e-mail]. Thank you.
Regards,
Jamie McGrath
EHS Manager
Southwire j Huntersville

Stormwater Discharge Monitoring Report
for North Carolina Division of Energy, Mineral and Land Resources General Permit No. NCG030000
Date submitted =' 3 Z 0
CERTIFICATE OF COVERAGE NO. NCG03 0 6 6 4
FACILITY NAME Southwire
COUNTY Mecklenburg
PERSON COLLECTING SAMPLES Jamie McGrath
LABORATORY pace Labs Lab Cert. #t 12
Comments on sample collection or analysis:
Part A: Stormwater Benchmarks and Monitoring Results
SAMPLE COLLECTION YEAR 2020
SAMPLE PERIOD Q Jan -June ❑ July -Dec
or ❑ Monthly' _ _ (month)
DISCHARGING TO CLASS ❑ORW ❑HCJW ❑Trout ❑PNA
❑Zero -flow ❑Water Supply ❑SA
Mother C•Waterbody
PLEASE REMEMBER TO SIGN ON PAGES 2 AND/OR 3 -)
❑ No discharge this period?'
Outfall No.
Date Sample
Collected)
(mo/dd/yr)
24-hour rainfall
amount,
Inches s
Total Suspended Solids
pH,
Standard units
Total Copper
Total Lead
Total Zinc
Non -Polar 0&G/
Total Petroleum
Hydrocarbons
Total Toxic
Organics
Benchmarks
_
100 mg/L or 50 mg/0
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
ROS Outfall #2
1/24/2020
0.30
1.8 mg/L
6.5
<0.0050 mg/L
<0.0050 mg/L
<0.010 mg/L
<5 mg/L
NIA
' Monthly sampling (instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
2 For sampling periods with no discharge at any single outfall, 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.
a 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 SdVU-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."
Jamie McGrath
Name (Print name)
EHS Manager
Title (Print title)
a2 3Z142e_
Si nature Date
07
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,
Inches'
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/L°
Parameter Code
-
46524
NCOI L
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 II 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 ANYONE OUTFALL? YES ❑ NO ❑
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME: James Moore [phone]
Moil an originol copy of this DMR, including aH "No Discharge" reiports, within 30 days of receipt of the lab results (or at end of monitoring period in the
case of "No Dischorge" 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."
I�
of Perm
�3�a6)
Date
Permit Date: 11/1/2018-05/31/2021 SWU-245, last revised 11/1/2018
Page 3 of 3

aceAnalytical'
www.picalibi.com
January 31, 2020
Jamie McGrath
Southwire
12331 Commerce Station Dr
Nuntersville, NC 28078
RE: Project: 2020 Semi -Annual Stormwater
Pace Project No.: 92462207
Dear Jamie McGrath:
Pace Analytical Services, LLG
205 East Meadow Road - Suite A
Eden, NC 27288
[phone]
Enclosed are the analytical results for sample(s) received by the laboratory on January 24, 2020.
The results relate only to the samples included in this report. Results reported herein conform to the
most current, applicable TNIINELAC 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,
Taylor Ezell
[e-mail]
[phone]
Project Manager
Enclosures
9Q9�A��
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 11

IceAnalytical
www.pacelahs.com
Project: 2020 Semi -Annual Stormwater
Pace Project No.: 92462207
Pace Analytical Services Charlotte
9800 Kincey Ave. Ste 100, Wuntersville, NC 28078
Louisiana/NELAP Certification # LA170028
North Carolina Drinking Water Certification #. 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
FloridalNELAP Certification #. E87648
Massachusetts Certification #: M-NC030
North Carolina Drinking Water Certification #: 37712
CERTIFICATIONS
South Carolina Certification #: 99006001
Flodda/NELAP Certification #: E87627
Kentucky UST Certification #: 84
VirginiafVELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
VirginiafVELAP Certification #: 460222
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Pace Analytical Services, LLC
205 East Meadow Road - Suite A
Eden, NC 27288
[phone]
Page 2 of 11

aceAnapical
www.pacolabs.com
SAMPLE ANALYTE COUNT
Pace Analytical Services, LLC
205 East Meadow Road - Suite A
Eden, NC 27288
[phone]
Project:
2020 Semi -Annual Stormwater
Pace Project No.:
92462207
Analysts
Lab ID
Sample ID
Method
Analysts
Reported
Laboratory
92462207001
ROS Outfall #2
EPA 16648
WAM
1
PASI-C
EPA 200.7 Rev 4.4 1994
RDT
3
PASI-A
SM 2540D-2011
MJP
1
PASI-A
EPA 9040C
ECM
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 11

aceAnalyfical
ww.p�ttla8s.tom
ANALYTICAL RESULTS
Pace Analytical Services, LLC
205 East Meadow Road - Suite A
Eden, NC 27288
[phone]
Project: 2020 Semi -Annual Stormwater
Pace Project No.: 92462207
Sample: ROS Outfall #2
Lab ID: 92462207001 Collected:
01/24120 08:10
Received: 01/24120 12:45 Matrix: Water
Parameters
Results Units Report Limit
DF
Prepared Analyzed CAS No. Qual
HEM, Oil and Grease
Analytical Method: EPA 1664E
Oil and Grease
ND mg1L
5.0
1
01/29/20 10:07
200.7 MET ICP
Analytical Method: EPA 200.7 Rev 4.4
1994 Preparation
Method: EPA 200.7 Rev 4.4 1994
Copper
ND mg1L
0.0050
1
01129/20 01:03 01/29/20 19:51 7440-50-8
Lead
ND mg1L
0.0050
1
01/29/20 01:03 01/29/20 19:51 7439-92-1
Zinc
ND mg1L
0.010
1
01/29/20 01:03 01/29/20 19:51 7440-66-6
2540D TSS, Low -Level
Analytical Method: SM 25400-2011
Total Suspended Solids
1.8 mg1L
1.0
1
01/28/20 13:19
9040 pH
Analytical Method: EPA 9040C
pH at 25 Degrees C
6.5 Std. Units
0.10
1
01127/20 12:54 H3
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 01 /31 /2020 04:22 PM without the written consent of Pace Analytical Services, LLC. Page 4 of 11

ace Analytical
www.pacelabs.corn
QUALITY CONTROL DATA
Project: 2020 Semi -Annual Stormwaler
Pace Project No.: 92462207
QC Batch: 522002 Analysis Method: EPA 1664B
QC Batch Method: EPA 1664E Analysis Description: 1664 HEM, Oil and Grease
Associated Lab Samples: 92462207001
METHOD BLANK: 2792140 Matrix: Water
Associated Lab Samples: 92462207001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Oil and Grease mg1L ND 5.0 01/29/20 10:07
Pace Analytical Services, LLC
205 East Meadow Road - Suite A
Eden, NC 27288
[phone]
LABORATORY CONTROL SAMPLE:
2792141
Spike LCS
LCS
% Rec
Parameter
Units
Conc. Result
% Rec
Limits
Qualifiers
Oil and Grease
mg1L
40 33.5
84
78-114
MATRIX SPIKE SAMPLE:
2792142
35524958003 Spike
MS
MS
% Rec
Parameter
Units
Result Conc.
Result
% Rec
Limits Qualifiers
Oil and Grease
mglL
127 40
197
175
78-114 M1
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: 01/31/2020 04:22 PM without the written consent of Pace AnaiyGcai Services, LLC. Page 5 of 11

aceAnalytrcal
www.parelabs.com
QUALITY CONTROL DATA
Project: 2020 Semi -Annual Stormwater
Pace Project No.: 92462207
Pace Analytical Services, LLC
205 East Meadow Road - Suite A
Eden, NC 27288
[phone]
QC Batch: 521932
Analysis Method: EPA 200.7 Rev 4A 1994
QC Batch Method: EPA 200.7 Rev 4.4 1994
Analysis Description: 200.7 MET
Associated Lab Samples: 92462207001
METHOD BLANK: 2791972
Matrix: Water
Associated Lab Samples: 92462207001
Blank Reporting
Parameter
Units
Result Limit
Analyzed Qualifiers
Copper
mg1L
ND 0.0050
01/29/2018:21
Lead
mg1L
ND 0.0050
01/2912018:21
Zinc
mg1L
ND 0,010
01129/2018:21
LABORATORY CONTROL SAMPLE: 2791973
Spike LCS
LCS % Rec
Parameter
Units
Conc. Result
% Rec Limits Qualifiers
Copper
mg/L
0.5 0.49
99 85-115
Lead
mg/L
0.5 0.49
98 85-115
Zinc
mg/L
0.5 0.48
96 85-115
MATRIX SPIKE & MATRIX SPIKE DUPLICATE:
2791974
MS
35525828001
Spike
Parameter Units
Result
Conc.
Copper mg/L
2.1 U
0.5
ug/L
Lead mg/L
1.61J
0.5
ug/L
Zinc mg/L
3.9U
0.5
ug/L
2791975
MSD
Spike
MS
MSD
MS
MSD
% Rec
Conc.
Result
Result
% Rec
% Rec
Limits RPD Qual
0.5
0.53
0.52
105
103
70-130 2
0.5
0.51
0.50
102
100
70-130 2
0.5
0.51
0.50
101
99
70-130 2
MATRIX SPIKE & MATRIX SPIKE DUPLICATE:
2791976
2791977
MS
MSD
92461813001 Spike
Spike
MS
MSD
MS
MSD
% Rec
Parameter Units
Result Conc.
Conc.
Result
Result
% Rec
% Rec
Limits RPD Qual
Copper mg/L
ND 0.5
0.5
0.51
0.51
101
102
70-130 1
Lead mg1L
ND 0.5
0.5
0.50
0.50
100
101
70-130 1
Zinc mg/L
NO 0.5
0.5
0.50
0.50
99
100
70-130 1
Results presented on this page are in the units indicated try the "Units- column except where an attemate unit is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 01/31/2020 04:22 PM without the written consent of Pace Analytical Services, LLC. Page 6 of 11

aceAnalytical
www pacelabs.com
QUALITY CONTROL DATA
Project: 2020 Semi -Annual Stormwater
Pace Project No.: 92462207
OC Batch: 521801 Analysis Method: SM 2540D-2011
QC Batch Method: SM 25400-2011 Analysis Description: 2540D Total Suspended Solids
Associated Lab Samples: 92462207001
METHOD BLANK: 2791463
Associated Lab Samples: 92462207001
Parameter Units
Total Suspended Solids mg1L
Matrix: Water
Blank Reporting
Result Limit Analyzed Qualifiers
ND 1.0 01/28/20 13:18
Pace Analytical Services, LLC
205 East Meadow Road - Suite A
Eden, NC 27288
[phone]
LABORATORY CONTROL SAMPLE & LCSD: 2791464 2791465
Spike LCS LCSD LCS LCSD % Rec Max
Parameter Units Conc. Result Result % Rec % Rec Limits RPD RPD Qualifiers
Total Suspended Solids mg/L 250 262 264 105 106 90-110 1 25
SAMPLE DUPLICATE: 2791466
92461760001 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg1L 785 745 5
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: 01/31/2020 04:22 PM without the written consent of Pace Analytical Services, LLC.
Page 7 of 11

aceAnalytical
www.pacelab3.com
Project: 2020 Semi -Annual Stormwater
Pace Project No.: 92462207
QC Batch: 521441
QC Batch Method: EPA 9040C
Associated Lab Samples: 92462207001
SAMPLE DUPLICATE: 2789651
Parameter Units
pH at 25 Degrees C Std. Units
SAMPLE DUPLICATE: 2789652
Parameter
pH at 25 Degrees C
QUALITY CONTROL DATA
Analysis Method: EPA 9040C
Analysis Description: 9040 pH
92460381001 Dup
Result Result RPD Qualifiers
7.5 7.3 2 D6,H3
92460752001 Dup
Units Result Result
Std. Units 7A 7.0
RPD Qualifiers
5 D6,H3
Pace Analytical Services, LLC
205 East Meadow Road - Suite A
Eden, NC 27288
[phone]
Results presented on thtx page are in the units indicated 4y the "Units' column except where an alternate unit is presented to the right of the resulL
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 01/31/2020 04:22 PM wittiout the written consent of Pace Analytical Services, LLC. Page 8 of 11

ace Analytical
www.pecolabs.com
Pace Analytical Services, LLC
205 East Meadow Road - Suite A
Eden, NC 27288
[phone]
QUALIFIERS
Project: 2020 Semi -Annual Stormwater
Pace Project No.: 92462207
DEFINITIONS
OF - 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.
MOIL -Adjusted Method Detection Limit.
PQL - Practical Quentitation Limit.
RL - Reporting Limit - The lowest concentration value that meets project requirements for quantitative data with known precision and
bias for a specific analyze 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
PAST -A Pace Analytical Services -Asheville
PASI-C Pace Analytical Services - Charlotte
ANALYTE QUALIFIERS
D6 The precision between the sample and sample duplicate exceeded laboratory control limits.
H3 Sample was received or analysis requested beyond the recognized method holding time.
M1 Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS) recovery.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full.
Date: 01/31/2020 04:22 PM without the written consent of Pace Analytical Services, LLC. Page 9 of 11

ace Analytical.e
rww.pecelabs.com
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: 2020 Semi -Annual Stormwater
Pace Project No.: 92462207
Lab ID
Sample ID
QC Batch Method
QC Batch
92462207001
ROS Outfall 92
EPA 1664E
522002
92462207001
ROS Outfall #2
EPA 200.7 Rev 4.4 1994
521932
92462207001
ROS Outfall #2
SM 2540D-2011
521801
92462207001
ROS Outfall #2
EPA 9040C
521441
Date: 01/31/2020 04:22 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Pace Analytical Services, LLC
205 East Meadow Road - Suite A
Eden, NC 27288
[phone]
Analytical
Analytical Method Batch
EPA 200.7 Rev 4.4 1994 521955
Page 10 of 11

0" ,)t CHAIN -OF -CUSTODY Analytical Request Document
PaceAnalytical '
Chain -of -Custody is a LEGAL DOCUMENT - Complete all relevent fields)
LAB USE ONLY-Af wo# : 92462207
III I I� II I I I I� III
ALL
92462207
Container Preservo.
Company:
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1 Preservative Types: (1) nitric acid, (2) sulfuric arid. (3] hydrochloric acid, (4) sodium hydroxide, (5) zinc acetate.
j6) methanul, {7) sodium biwliare, (B) sodium thiosullaw, (9) hexane, {A) a5mrbiC acid. (8) ammonium sul aw,
C) ammonium hydroxide. (D) TSP, JU) Unpreserved, (0) Other
Copy T6:
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State: j pCoun `y/ ity: ,�•TmeZone o ected:
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Lab Sample Receipt Chockligt:
Custody Seals Present/Intact Y 140.
custody Signatures present v�N t[IN
Cot lector signature Present NA
Bottles Intact N NA
correct Bottles tl 14A
Sufficient volume N t4a
Sampler; Received on Lee rCa7 N
VOA - Headspace Aceeptable Y N Ylt4'
USDA Regulated Soils�N r�i]%samples in ;adding Time [YEN HA
Residual Chlorine PreoenL Y N qo,
C1 Strips: I ��
Sample pH Acce�tab la �, V V f LJ " HA
pH Strips: o- ��[.
Sulfide Present Y N Nfi
Lead Acetate Strips: _-
LAB USE aNLY:
Lab sample h / Comments :
7
L� l
Phone:'��1{
Email:�..�
Site/ cilily ID #: }
- 11�i
Co ;ante Monitoring?
[ Yes [ ] No
c cted.By rant : ��y
\JAMw a SY`
Purchase Order #: iY !12
Quote #: "[ (J
DW PWS tD N:
DW Location Code:
lotted By (sign ure
M"aly
Turnaround Date
�jRequi ed;
Imme late y Pac a On Ice.
Yes [ INU
H le O.
[� Dispose as appropriate I I Return
I I Archive:
I ;Hold-
Rush:
[ ] Same Day [ ] Next Day
[ 12 Day [ 13 Day ( ] 4 Day I 15 Day
(Expedite Charges Apply)
Field Filtered (if ap licab)e);
[ ] Yes [Vd
Analysis:
' Matrix Codes (insert in Matrix box below): Drinking Water (DW), Ground Water (GWI, Wastewater (WW),
Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
Customer Sample ID
Matrix
Camp /
Grab
Collected (or
Composite Start)
Composite End
Res
Cl
# of
Ctns
Date
Time
Date
Time
US 6 '1! 421
CustuHtet Remarks / Special Conditions / Posslile Hazards:
Type of Ice Used: a Blue Dry None
SHORT HOLDS PRESENT (<72 hoursj: Y - N/A
tab Sample Temperature Info:
Temp Blank < Y
Therm ID#: /d
Cooler 1 Temp Upon Receipt: /1/ oC
Cooler 1 Therm Corr. Factor: uC
Cooler 1 Corrected Temp:oC
Comments:
Packing Material Used: ,
Vy
Lab Tracking #: I O
2416140
Radchem sample(s) screened (<506 cpm): Y N NA
Samples received via:
FEDEX UPS ient Courier Pace Courier
y: (Signature)
1;4i6w 5b i
Date
,,/��Ti��e: Y�r
7m
r,!/"1Gt✓Gu pq
Received by/ ny: (Signature)
- IP%
Date/Time: ''�/
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MTfL LAB USE ONLY
Table #:
Acctnum:
Template:
Prelogin:
linquished by/Company: (Signature)
Date/Time:
Rece y/Company: (Signature)
Date/Time:
Trip NA Blank Received; Y N (
HCL McOH TSP Other
�hnquishecl by/Company: (Signature)
Date/Time:
Received by/Company: (Signature]
Date/Time:
PM:
pB:
Non Conform ce(s);
YES /
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of: