NCG060354_MONITORING INFO_20190204

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
/V O �j D35 y
DOC TYPE
0 HISTORICAL FILE
iQ.MONITORING REPORTS
DOC DATE
❑ J Oi'I D --) D '7
YYYYMMDD

January 13, 2020
NC Department of Environment and Natural Resources
Division of Water Quality
1617 Mail Service Center
Raleigh, NC 27699-1617
Attention: Central Files
Subject: Discharge Monitoring Reports 11
NPDES General Permit No. NCG060000
COC# NCG060354 (R11R2)
Hospira, A Pfizer Company— Nash County
To Whom It May Concern:
A Company
RECEIVED
FEe 04 20 19
CENrRk FILES
DWR SECrlj
Per the requirements of our general stormwater permit, the following documentation is
attached for your review;
✓ Storm water Discharge Monitoring Reports for Outfalls 004B, 005, 017A
✓ Certified laboratory report
All required discharge characteristics (total suspended solids, pH, oil and grease, and
chemical oxygen demand) were within permitted ranges. Total rainfall was measured
with an on -site rain gauge for the duration of the event. We will continue to conduct
future sampling events based on the conditions indicated in our permit.
Please contact me at [phone] if you have any questions or I can provide any additional
information.
Sincerely,
Samuei Toke
EHS Manager
Hospira, a Pfizer company
4285 N. Wesleyan Blvd.
Rocky Mount, NC 27804

SEMI-ANNUAL STORMWATER DISCHARGE MONITORING REPORT
for North Carolina Division of Water Quality General Permit No. NCG060000
Date submitted 01/13/2020
CERTIFICATE OF COVERAGE NO. NCG06 0 3 5 4 SAMPLE COLLECTION YEAR 2019
FACILITY NAME Hospira, a Pfizer company (Rocky Mount, FACILITY ACTIVITIES INCLUDE (check all that apply):
NQ ❑ use/process meats ❑ use animal fats/byproducts
COUNTY Nash DISCHARGING TO SALTWATERS? ❑YES ®NO
PERSON COLLECTING SAMPLES Mike Lewis
LABORATORY Pace Analytical Lab Cert. # PASI-C #12, PASI-A #40 PLEASE REMEMBER TO SIGN ON THE REVERSE 4
Part A: Stormwater Benchmarks and Monitoring Results
Total event rainfall '_.3 or ❑ No discharge this period3
Outfall No.
Sample, Collected,
mo/dd/yr
TSS,
mg/L
pH,
Standard units
COD,
mg/L
Oil and Grease,
mg/L
Fecal Coliforml,
Colonies per 100 ml
Enterococci',
Colonies per 100 ml
Benchmark
-
100 or 504
Within 6.0 — 9.0
120
30
1000
Soo
004E
12/17/19
3.3
6.74
<25.0
<4.8
N/A
N/A
005
12/17/19
11.5
7.21
<25.0
<4.9
N/A
N/A
017A
12/17/19
19.2
7.57
27.8
<4.9
N/A
N/A
1 Only applies to facilities that use/process meats.
2 The total precipitation must be recorded using data from an on -site rain gauge.
3 For sampling periods with no discharge at any outfalls. You must still submit this discharge monitoring report with a checkmark here.
'See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ❑ yes ® no
Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging > 55 gal of new motor oil/month.
Outfall No.
Sample Collected,
mo/dd/yr
Oil and Grease,
mg/L
TSS,
mg/L
pH,
Standard units
New Motor Oil Usage,
Annual average gal/mo
Benchmark
-
30
100 or 504
6.0 — 9.0
-
N/A
N/A
N/A
N/A
N/A
N/A
1 Only applies to facilities that use/process meats.
2The total precipitation must be recorded using data from an on -site rain gauge.
3 For sampling periods with no discharge at any outfalls, you must still submit this discharge monitoring report with a checkmark here.
'See General Permit text, Table 3, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
(ides, complete Part B)
RECEIVED
FEB 0 4 2m
CENTRAL FILES
DWR SECTION
SWU-249 Last Revised: October 18, 2012
Page 1 of 2

*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 ANY ONE OUTFALL? YES ❑ NO
IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME: N/A
Mail an original and one copy of this DMR, including all "No Discharge" reports, within 30 days of receipt of the lab results (or at end of
monitoring period in the case o "No Discharge" reports) to:
Division of Water Quality
Attn: DWQ Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED:
"1 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."
PI'—�r¢A/--ac.-7a
(Date)
Additional copies of this form may be downloaded at: http://Portal.ncdenr.org/web/wQ/ws/su/nodessw#tab-4
S WU-249 Last Revised: October 18, 2012
Page 2 of 2

Stormwater DMR Sampling
Sample Date Event Start Time Event Rainfall
7I/1
TI/
150
013
Outfall No. 004B (LVP)
Time
pH
Temperature
Outfall No. 005 (FCF)
Time
pH
7,X)
Temperature
/�, j pC
Outfall No. 017A (R2)
Time
pH
Temperature
Sampled by: ;W,./�/ /-)'/ 71J 7

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WVft+ WAh&cam
December 31, 2019
Michael A. Lewis
Hospira, Inc. - Rocky Mount, NC
4285 N. Wesleyan Blvd.
Rocky Mount, NC 27804
RE: Project: Stormwater
Pace Project No.: 92458192
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Dear Michael Lewis:
Enclosed are the analytical results for sample(s) received by the laboratory on December 19, 2019,
The results relate only to the samples included in this report.
Analyses were performed at the Pace Analytical Services location indicated on the sample analyte
page for analysis unless otherwise footnoted.
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
Matthew Brainard
[e-mail]
[phone]
Project Manager
Enclosures
cc: Samuel Toke, Hospira- Rocky Mount
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 14

aceAnalytical®
urm.pawabs.com
Project: Stormwater
Pace Project No.: 92458192
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Pace Analytical Services Charlotte
9800 Kincey Ave. Ste 100, hiuntersville, 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
Florida/NELAP Certification #: E87648
Massachusetts Certification #: M-NC030
North Carolina Drinking Water Certification #: 37712
CERTIFICATIONS
South Carolina Certification #: 99006001
FloridalNELAP Certification #: E87627
Kentucky UST Certification #: 84
VirginiaNELAP Certification #: 460221
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
VirginiaNEI-AP 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 14

aceAnalytical
t+ m.paeatabs.eam
SAMPLE ANALYTE COUNT
Project: Stormwater
Pace Project No.: 92458192
Pace Analytical Servlcea, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Lab ID
Sample ID
Method
Analysts
Analytes
Reported
Laboratory
92458192001
0UTFALL 017
EPA 1664E
HH
1
PASI-C
SM 2540D-2011
MJP
1
PASI-A
SM 5220D-2011
JP1
1
PASI-A
92458192002
OUTFALL 004E
EPA 1664B
HH
1
PASI-C
SM 25401)-2011
MJP
1
PASI-A
SM 5220D-2011
JP1
1
PASI-A
92458192003
OUTFALL 005
EPA 1664E
HH
1
PASI-C
SM 254OD-2011
MJP
1
PASI-A
SM 5220D-2011
JP1
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 14

aceAnalytical
WWW.paeelabs.cmn
ANALYTICAL RESULTS
Pace Analytical Services, LLC
67011 Conference Drive
Raleigh, NC 27607
[phone]
Project: Stormwater
Pace Project No.: 92458192
Sample: OUTFALL 017 Lab ID: 92458192001 Collected: 12/17119 11:48 Received: 12/19/19 08:46 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
HEM, Oil and Grease Analytical Method: EPA 1664B
Oil and Grease ND mg1L 4.9 1 12/31/19 09:11
2540D Total Suspended Solids Analytical Method: SM 254OD-2011
Total Suspended Solids 19.2 mg/L 4.2 1 12/23/19 18:14
5220D COD Analytical Method: SM 5220D-2011 Preparation Method: SM 5220D-2011
Chemical Oxygen Demand 27.8 mg/L 25.0 1 12124/19 23:23 12/25/19 07:01
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 12/31 /2019 02:35 PM without the written consent of Pace Analytical Services, LLC. Page 4 of 14

aceAnalytical
rrw.pacdabsrom
ANALYTICAL RESULTS
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Project: Slormwater
Pace Project No.: 92458192
Sample: OUTFALL 004E Lab ID: 92458192002 Collected: 12/17/19 10:40 Received: 12/19/19 08:46 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed GAS No. Oual
HEM, Oil and Grease Analytical Method: EPA 1664E
Oil and Grease ND mg/L 4.8 1 12/31/19 09:12
2540D Total Suspended Solids Analytical Method: SM 254OD-2011
Total Suspended Solids 3.3 mg/L 2.7 1 12/23/19 18:14
5220D COD Analytical Method: SM 5220D-2011 Preparation Method: SM 5220D-2011
Chemical Oxygen Demand ND mg/L 25.0 1 12/24/19 23:23 12/25/19 07:01
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 12/31/2019 02:35 PM without the written consent of Pace Analytical Services, LLC. Page 5 of 14

aceAnalytrcal
MMMf penult iza
ANALYTICAL RESULTS
Pace Analytical Services, LLC
6701 Conference Strive
Raleigh, NC 27607
[phone]
Project: Stormwater
Pace Project No.: 92458192
Sample: OUTFALL 005 Lab ID: 92458192003 Collected: 12/17119 11:22 Received: 12/19/19 08:46 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Ouai
HEM, Oil and Grease Analytical Method: EPA 1664B
Oil and Grease ND mglL 4.9 1 12/31/19 09:13
2540D Total Suspended Solids Analytical Method: SM 254OD-2011
Total Suspended Solids 11.5 mg1L 2.5 1 12/23/19 18:15
5220D COD Analytical Method: SM 5220D-2011 Preparation Method: SM 5220D-2011
Chemical Oxygen Demand ND mg/L 25.0 1 12/24/19 23:23 12/25/19 07:02
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 12131/2019 02:35 PM without the written consent of Pace Analytical Services, LLC. Page 6 of 14

ace Analytical
W".paaiiII&cola
QUALITY CONTROL DATA
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
(919)B34-4984
Project: Stormwater
Pace Project No.: 92458192
QC Batch: 517358
Analysis Method:
EPA 1664E
QC Batch Method: EPA 1664B
Analysis Description:
1664 HEM, Oil and Grease
Associated Lab Samples: 92458192001, 92458192002, 92458192003
METHOD BLANK: 2770344
Matrix: Water
Associated Lab Samples: 92458192001, 92458192002, 92458192003
Blank Reporting
Parameter
Units
Result Limit
Analyzed Qualifiers
Oil and Grease
mg/L
ND 5.0 12/31/19 09:04
LABORATORY CONTROL SAMPLE:
2770345
Spike LCS
LCS % Rec
Parameter
Units
Conc. Result
% Rec Limits Qualifiers
Oil and Grease
mg/L
40 32.0
80 78-114
MATRIX SPIKE SAMPLE:
2770346
92457560002 Spike
MS MS % Rec
Parameter
Units
Result Conc.
Result % Rec Limits Qualifiers
Oil and Grease
mg/L
ND 38.5
16.7 40 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: 12/31/2019 02:35 PM without the written consent of Pace Analytical Services, LLC.
Page 7 of 14

aceAnalytica!
wir*.patdltts.tom
QUALITY CONTROL DATA
Project: Stormwater
Pace Project No.: 92458192
QC Batch: 516469 Analysis Method: SM 254OD-2011
QC Batch Method: SM 254OD-2011 Analysis Description: 2540D Total Suspended Solids
Associated Lab Samples: 92458192001, 92458192002, 92458192003
Pace Analytical Services, I.LC
6701 Conference Drive
Raleigh, NC 27607
[phone]
METHOD BLANK: 2767268
Matrix: Water
Associated Lab Samples: 92458192001, 92458192002, 92458192003
Blank
Reporting
Parameter
Units
Result
Limit
Analyzed Qualifiers
Total Suspended Solids
mg/L
ND
2.5
12/23/19 18:11
LABORATORY CONTROL SAMPLE:
2767270
Spike
LCS
LCS % Rec
Parameter
Units
Cone.
Result
% Rec Limits Qualifiers
Total Suspended Solids
mg/L
251
246
98 90-110
SAMPLE DUPLICATE: 2767271
92458028003
Dup
Parameter
Units
Result
Result
RPD Qualifiers
Total Suspended Solids
mg1L
125
128
2
SAMPLE DUPLICATE: 2767272
92458406001
Dup
Parameter
Units
Result
Result
RPD Qualifiers
Total Suspended Solids
mg/L
53.8
35.1
42 06
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: 12/31 /2019 02:35 PM without the written consent of Pace Analytical Services, LLC, Page 8 of 14

aceAnalytical
ww-p=W lbs.com
QUALITY CONTROL DATA
Project: Stormwater
Pace Project No.: 92458192
QC Batch: 516655 Analysis Method: SM 5220D-2011
QC Batch Method: SM 5220D-2011 Analysis Description: 5220D COD
Associated Lab Samples: 92458192001, 92458192002, 92458192003
METHOD BLANK: 2767990 Matrix: Water
Associated Lab Samples: 92458192001, 92458192002, 92458192003
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Chemical Oxygen Demand mg/L ND 25.0 12/25119 06:57
Paco Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
LABORATORY CONTROL SAMPLE: 2767991
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Chemical Oxygen Demand mg1L 750 762 102 90-110
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2768004 2768005
MS MSD
92458100001 Spike Spike MS MSD MS MSD % Rec
Parameter Units Result Conc. Conc. Result Result % Rec % Rec Limits RPD Qual
Chemical Oxygen Demand mg/L 82.5 100 100 187 194 105 112 90-110 4 M1,R1
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2768006 2768007
MS MSD
92458369003 Spike Spike MS MSD MS MSD % Rec
Parameter Units Result Conc. Conc. Result Result % Rec % Rec Limits RP❑ Qual
Chemical Oxygen Demand mg1L ND 100 100 121 121 109 109 90-110 0
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: 12/31/2019 02:35 PM without the written consent of Pace Analytical Services, LLC.
Page 9 of 14

lacieAnalyficale
•rsr psatsbs.c m
QUALIFIERS
Project: Stormwater
Pace Project No.: 92458192
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.
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
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 anatyte in a specific matrix.
S - Surrogate
1,2-Diphenylhydrazine decomposes to and cannot be separated from Azobenzene using Method 13270. 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 SV11846 Chapter 4 for the analysis of Acrolein and Acrylonitrile by EPA
Method 8260.
N-N itrosod iphenyla mine decomposes and cannot be separated from Diphenylamine using Method 8270. The result reported for
each analyte is a combined concentration.
LABORATORIES
PASI-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.
M1 Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS) recovery.
R1 RPD value was outside control limits.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 12131 /2019 02:35 PM without the written consent of Pace Analytical Services, L.I.C. Page 10 of 14

e
aceAnaljftal
wxr.patalatos.com
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: Stormwater
Pace Project No.: 92456192
Pace Analytical Services, LLC
6701 Conference Drive
Raleigh, NC 27607
[phone]
Lab ID Sample ID QC Batch Method QC Batch Analytical Method
92458192001
OUTFALL 017
EPA 1664E
517358
92458192002
OUTFALL 004B
EPA 1664B
517358
92458192003
OUTFALL 005
EPA 1664E
517358
92458192001
OUTFALL 017
SM 25400-2011
516469
92458192002
OUTFALL 004E
SM 254OD-2011
516469
92458192003
OUTFALL 005
SM 25400-2011
516469
92458192001
OUTFALL 017
SM 5220D-2011
516655 SM 52200-2011
92458192002
OUTFALL 004B
SM 5220D-2011
516655 SM 5220D-2011
92458192003
OUTFALL 005
SM 5220D-2011
516655 SM 5220D-2011
Date: 12131/2019 02:35 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in ful,
without the written consent of Pace Analytical Services, LLC.
Analytical
Batch
516665
516665
516665
Page 11 of 14

Document Name: Document Revised: February 7, 2019
Sam a Condition Ll 4n Recalpt(SCURJ Pa e 1 of 2
aCVA&,VybM • Document No,: Issuing Authority:
F-CAR-CS-033-RevAg Face Carolinas Quality Office
Laboratory receiving samples;
Asheville Eden[] Greenwood ❑ Huntersvifle❑ Ralellihg] Mechanirsvilie❑
• SEEM Protect g: Client Name: WO# : 92458A2
I� �l
t L
Courier: ❑Fed Ex UPS USPPS ` Client
❑ Commercial 2Pace ❑Other 92458192
Custody Sea( Present? ElYes ONo Seats intact? ❑Yes &c,
DateAriftfah pefsan Eramfning Contents:__Zp-1A
Packing Material: []Bubble Wrap SSubble Sags ❑None ❑ Other Biological Tissue Frozen?
Thermometer. a IT Type of Ice: 0 0 � []WetQ8lue C]Nms []Yes QN4 ®N/A
�lA Gun 10: �
Cooler Temp ('C): • 0.2)
Correction Factor: Add/Subtract ('C) Q . U
Temp should be above freezing to VC
Cooler Temp Corrected ('C): []Samples out oftemp crherta. Samples on Ice, cooling process
hu begun
USDA Regulated Soil ([f N/A, water sample)
Did samples originate In a quarantine zone within the United States: CA, NY, or SC (check maps)? Did samples erlglnate from a foreign source (Intemat(onally,
nYes nNo rndudina kaunll and h,erea Atml7 f—Wes r1Na
Coraments/Discrepaing,
Chain at Custody Present?
es
QNo
N/A
L
Samples Arrived within Hold Time?
&eS
QNQ
ONIA
L
Short Hold Time Anal)L51! (Q2 hr.)?
19Yes
❑No
WA
3.
Rush Turn Around Time Requested?
UN
&.
ONJA
4.
SuffirientValume?AY,
[]No
N/A
5.
Correct Containers Used?
-Paco Containers Used?
flYes
Yes
ONO
IN.
❑N/A
N/A
6.
containers
containerslntact7
Yes
No
N/A
7.
analysts: Samples Field Filtered?
Yes
o
N A
S.
Sample Labels Match COC?
-Indudes Oate.Mmi fiD/Ana is Matrix:
oyes
C
ONO
ON/A
9.
Headspace in VOA Vials (>S�mm)7
Yes
ON.
�"
,�/A
10.
Trip Blank Present?
Trip Blank Custody Seats Present?
Dag
Dyes
ONO
Na
QN/A
N/A
11.
COMMENTS/SAMPLE DISCREPANCY
Lot ID of split containers
CLIENT NOTIFICATION/RESOLUTION
Person contacted:
Date/TIME:
field Data Raqulred? []Yes []No
a
Project Manager SCURF Review:
Data:
Project Manager SRF Review:
Date:
Page 12 of 14
rr�—

Document Name: DacumenCRevfsed: February 7, 2018
!r� SAm !e tttnditian U on Revel t SCfJR Page 1 of 2
! •••' BCeRll�IytiCd�� - bacumcntNa.: IsslringAuihortty:
FtARrCB•033=Ray.06 Pace Carolinas QualFly Ofiflce
'Check mark top half of box If pH and/or dechlor€nat€on is project Ff-V2458192
ver€fled and within the acceptance range for preservation WO
samples. . PM; t4WB Cue pats: 12/31/19
aceptlons: VOA, Collform, TOC, Oil and Grease, ORDISO115 (water) Doc, uNg CLIENT' 91-14egp i re
"Bottom half of box is to list number of bottle
S T3 m d14
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17
1z
pH Adjustment Log for Preserved Samples
Sample if) Type of Preservative
pH upon recelpt
Date preservation adjusted
Time preservatlon
adjusted
Amount of preservative
added
lot p
Note: wnenever there Is a dLscrepaacy affecting North Cafollns mmpliance samples, a copy or tnu Form ami oe sent m the harm tareuna UHINK Leruncanan UMM Ire.
Out of hold, incorract preservative, out of temp, incorrect containers. Page 13 of 14

;' ;�atewaat�tiTar
Section A
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CHAIN -OF -CUSTODY 1 Analytical Request Document
The Chain-W-Custody is a LEGAL DOCUMENT. All relevant fields must be completed accurately.
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Invoice bdor natkrn:
Paae • t Ot t
Compwy. i Ho5Ora, Inc•Rodry Mount NC
Repo: To: klichad LcwiS
Aum1orr.
drew; 4285 K Weveym 91rd
Copy To:
Company Name:
Rodcv Wlorall. NC ZrW4
Address:
✓ty4� :.: `� — _ ••
Bwflt midwd.alewlsOPflxer.Com
Pumtn Oroer a: z
pool, ouare:
Phony 1 (52)97'-5433 Fa�c
Pr*ct Name: Srormwmer
Pace Proota Manages rnatlnaw.brana+up .cam.
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Requ"cd this Date:
Project /:
lam Profile e; 4733-2
NC
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