NCG120064_DMR_20200702

51
June 23, 2020
Chambers Development of NC, Inc. and
Waste Connections of the Carolinas, Inc.
Anson Waste Management Facility
375 Dozer Road
Polkton, NC 28135
Attention: Mr. Tyler Fitzgerald
Reference: Monthly Stormwater Monitoring
Anson Waste Management Facility
Polkton, North Carolina
S&ME Project No. 4140-15-007
Dear Mr. Fitzgerald:
JUL v 2 2020
„ o ;
DEQ-FAYETT VILLEREGIONALOFFICE
S&ME, Inc. (S&ME) is pleased to submit this report detailing the results of the June 2020 stormwater monitoring
activities conducted at the Anson Waste Management Facility (AWMF) in Polkton, North Carolina. This work was
completed in accordance with our Master Services Agreement dated January 2, 2017, and in accordance with Task
2 in S&ME Proposal No. 41-7600394 (Rev. 1) dated August 8, 2016. This letter summarizes results of sampling
efforts conducted by facility personnel.
® Background
Stormwater sampling is required on a semi-annual basis as defined by the National Pollutant Discharge
Elimination System (NPDES) General Permit for Landfills NCG120000 for the facility outfalls. The following outfalls
are identified at the facility: Outfall 1, Outfall 2, Outfall 3, Outfall 4, Borrow Area North Outfall, and Borrow Area
West Outfall. Outfall 2 was eliminated in August 2018 by the expansion of Sediment Basin 3 and, therefore, is no
longer sampled. Monthly sampling has been initiated following December 2019 results at Outfall 3 and Outfall 4,
in response to Tier 2 and Tier 3 response actions at the facility. Parameters for quantitative analysis include
chemical oxygen demand (COD) per Standard Method (SM) 2540D, fecal coliform per SM 9222D, and total
suspended solids (TSS) utilizing SM 2540D. In addition to the previously listed parameters, Outfall 1 and Outfall 3
are also sampled for chemical parameters associated with vehicle maintenance which include total petroleum
hydrocarbons (TPH) per Environmental Protection Agency (EPA) Method 1664E and pH utilizing SM 4500.
Stormwater Sampling and Quantitative Analyses
AWMF personnel collected the June stormwater samples at two (2) designated outfall locations on June 16, 2020.
The total rainfall for the June 16, 2020 storm event was reported as approximately 0.45 inch in 24 hours. Sampling
was performed during that storm event.
S&ME, Inc. 1 644 Eastern Star Road I Kingsport, TN 37663 1 p 423.349.2800 1 www.smeinc.com

g P
Monthly Stormwater Monitoring
Anson Waste Management Facility
S&ME Project No. 4140-15-007
Quantitative chemical laboratory results for the monitoring event are compared to benchmark values as
established by your NPDES permit on the attached Discharge Monitoring Report (DMR). Exceedances of
benchmark values are summarized in bold type below for your reference.
Benchmark
120
100 1000
"
15
6 - 9
Outfall 3
Sed Basin 3
67.9
8.2
27.0
<5.0
6.32
Outfall 4
Sed Basin 4
83.7
233
450
ANR
6.51
ANR = Analyte not requested and not required by the NPDES Permit
mg/i= milligrams per liter
CFU/ml= colony -forming units per milliliter
The DMR is included with this letter as Attachment] for your signature and submittal to the North Carolina
Department of Environmental Quality (NCDEQ), Division of Water Quality. The Laboratory Data Report for this
sampling event is included as Attachment H for your records.
Closure
S&ME appreciates this opportunity to be of service to you and Waste Connections. We trust this information is
responsive to your needs at this time. If you have any questions, please contact us at your convenience.
Sincerely,
S&ME, Inc.
1
rdAOrris
X
James R. Bruce
Project Manager
Senior Reviewer
Attachments: Discharge Monitoring Report
Laboratory Data Report
Site SWPPP Map
cc: Mike Lawyer, Fayetteville Regional Office
Lana Brown, Waste Connections
Nelson Breeden, Waste Connections of the Carolinas, Inc.
Page 2

Attachments

Attachment I Discharge Monitoring Report

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Attachment II — Laboratory Data Report

aceAnalytical
www.pacelabs.com
June 22, 2020
Lindsey Harris
SWE, Inc.
644 Eastern Star Road
Kingsport, TN 37663
RE: Project: Anson LF Stormwater - Monthly
Pace Project No.: 92482046
Dear Lindsey Harris:
• Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Enclosed are the analytical results for sample(s) received by the laboratory on June 16, 2020. The results relate only to the
samples included in this report. Results reported herein conform to the applicable TNI/NELAC Standards and the
laboratory's Quality Manual, where applicable, unless otherwise noted in the body of the report.
The test results provided in this final report were generated by each of the following laboratories within the Pace Network:
• Pace Analytical Services -Asheville
• Pace Analytical Services - Charlotte
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
Angela Baioni
[e-mail]
[phone]
Project Manager
Enclosures
Wit 'y�1
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 15

1aceAnaljdical
www.picalabs.com
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
CERTIFICATIONS
Project: Anson LF Stormwater - Monthly
Pace Project No.: 92482046
Pace Analytical Services Charlotte
9800 Kincey Ave. Ste 100, Huntersville, NC 28078 South Carolina Certification #: 99006001
Louisiana/NELAP Certification # LA170028 Florida/NELAP Certification #: E87627
North Carolina Drinking Water Certification #: 37706 Kentucky UST Certification #: 84
North Carolina Field Services Certification #: 5342 VirginiaNELAP Certification #: 460221
North Carolina Wastewater Certification #: 12
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804 North Carolina Wastewater Certification #:,40
Florida/NELAP Certification* E87648 South Carolina Certification M 99030001
Massachusetts Certification #: M-NC030 Virginia/VELAP Certification M 460222
North Carolina Drinking Water Certification #: 37712
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 15

u �Iac
1
eAnalytical
www.picalabo.com
SAMPLE ANALYTE COUNT
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Project: Anson LF Stormwater - Monthly
Pace Project No.: 92482046
Analytes
Lab ID Sample ID Method Analysts Reported Laboratory
92482046001 Outfall 3
92482046002 Outfall4
92482046003 Outfall1
PASI-A = Pace Analytical Services - Asheville
PASI-C = Pace Analytical Services - Charlotte
EPA 1664B
WAM
SM 9222D-2006
KDF
SM 2540D-2011
RED
SM 5220D-2011
LMS1
SM 9222D-2006
KDF
SM 254OD-2011
RED
SM 5220D-2011
LMS1
EPA 1664E
WAM
REPORT OF LABORATORY ANALYSIS
1
PASI-C
1
PASI-C
1
PASI-A
1
PASI-A
1
PASI-C
1
PASI-A
1
PASI-A
1
PASI-C
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC. Page 3 of 15

aceAnaijdical
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SUMMARY OF DETECTION
Project: Anson LF Stormwater - Monthly
Pace Project No.: 92482046
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Lab Sample ID
Client Sample ID
Method
Parameters
Result
Units
Report Limit
Analyzed Qualifiers
92482046001
Outfall 3
SM 9222D-2006
Fecal Coliforms
27.0
CFU/100 mL
1.0
06/17/20 13:51
SM 254OD-2011
Total Suspended Solids
8.2
mg/L
3.0
06/18/20 18:20
SM 5220D-2011
Chemical Oxygen Demand
67.9
mg/L
25.0
06/18/20 17:04
92482046002
Outfall 4
SM 9222D-2006
Fecal Coliforms
450
CFU/100 mL
1.0
06/17/20 13:51
SM 254OD-2011
Total Suspended Solids
233
mg/L
17.9
06/18/20 18:21
SM 5220D-2011
Chemical Oxygen Demand
83.7
mg/L
25.0
06/18/20 17:04
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC. Page 4 of 15

aceAnalytical
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ANALYTICAL RESULTS
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Project: Anson LF Stormwater - Monthly
Pace Project No.: 92482046
Sample: Outfall 3 Lab ID: 92482046001 Collected: 06/16/20 09:45 Received: 06/16/20 10:00 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
1664 SGT-HEM, TPH Analytical Method: EPA 1664B
Pace Analytical Services - Charlotte
Total Petroleum Hydrocarbons ND mg/L 5.0 1 06/19/20 15:09
MBIO 9222D Fecal Coliform CHT Analytical, Method: SM 9222D-2006 Preparation Method: SM 9222D-2006
Pace Analytical Services - Charlotte
Fecal Coliforms 27.0 CFU/100 mL 1.0 1 06/16/20 14:29 06/17/20 13:51
2540D Total Suspended Solids Analytical Method: SM 2540D-2011
Pace Analytical Services -Asheville
Total Suspended Solids 8.2 mg/L 3.0 1 06/18/20 18:20
5220D COD Analytical Method: SM 5220D-2011 Preparation Method: SM 6220D-2011
Pace Analytical Services -Asheville
Chemical Oxygen Demand 67.9 mg/L 25.0 1 06/17/20 17:01 06/18/20 17:04
Sample: Outfall 4 Lab ID: 92482046002 Collected: 06/16/20 09:30 Received: 06/16/20 10:00 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
MBIO 9222D Fecal Coliform CHT Analytical Method`. SM 9222D-2006 Preparation Method: SM 9222D-2006
Pace Analytical Services - Charlotte
Fecal Coliforms 450 CFU/100 mL 1.0 1 06/16/20 14:29 06/17/20 13:51
2540D Total Suspended Solids Analytical Method: SM 254OD-2011
Pace Analytical Services -Asheville
Total Suspended Solids 233 mg/L 17.9 1 06/18/20 18:21
6220D COD Analytical Method: SM 5220D-2011 Preparation Method: SM 5220D-2011
Pace Analytical Services -Asheville
Chemical Oxygen Demand 83.7 mg/L 25.0 1 06/17/20 17:01 06/18/20 17:04
Sample: Outfall 1 Lab ID: 92482046003 Collected: 06/16/20 00:00 Received: 06/16/20 10:00 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qua[
1664 SGT-HEM, TPH Analytical Method: EPA 1664B
Pace Analytical Services - Charlotte
Total Petroleum Hydrocarbons ND mg/L 5.0 1 06/19/20 15:09
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 06/22/2020 08:39 AM without the written consent of Pace Analytical Services, LLC. Page 5 of 15

aceAna1j4ica1
www.pacelabs.com
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
QUALITY CONTROL DATA
Project: Anson LF Stormwater - Monthly
Pace Project No.: 92482046
QC Batch: 548481 Analysis Method: EPA 1664B
QC Batch Method: EPA 1664B Analysis Description: 1664 SGT-HEM, TPH
Laboratory: Pace Analytical Services - Charlotte
Associated Lab Samples: 92482046001, 92482046003
METHOD BLANK: 2917886
Associated Lab Samples: 92482046001, 92482046003
Parameter Units
Total Petroleum Hydrocarbons mg/L
LABORATORY CONTROL SAMPLE: 2917887
Parameter Units
Total Petroleum Hydrocarbons mg/L
Matrix: Water
Blank Reporting
Result Limit Analyzed Qualifiers
ND 5.0 06/19/2015:09
Spike LCS LCS % Rec
Conc. Result % Rec Limits Qualifiers
20 18.7 94 64-132
MATRIX SPIKE SAMPLE: 2917888
92482046001 Spike MS MS % Rec
Parameter Units Result Conc. Result % Rec Limits Qualifiers
Total Petroleum Hydrocarbons mg/L ND 20 15.6 75 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: 06/22/2020 08:39 AM without the written consent of Pace Analytical Services, LLC.
Page 6 of 15

acooAnalXical
www.pacelabs.com
QUALITY CONTROL DATA
Project: Anson LF Stormwater - Monthly
Pace Project No.: 92482046
QC Batch: 547605 Analysis Method: SM 9222D-2006
QC Batch Method: SM 9222D-2006 Analysis Description: 9222D Fecal Coliform(MF) - CHT
Laboratory: Pace Analytical Services - Charlotte
Associated Lab Samples: 92482046001, 92482046002
METHOD BLANK: 2914253 Matrix: Water
Associated Lab Samples: 92482046001, 92482046002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Fecal Coliforms CFU/100 mL ND 1.0 06/17/20 13:51
SAMPLE DUPLICATE: 2914254
92482034004 Dup
Parameter Units Result Result RPD Qualifiers
Fecal Coliforms CFU/100 mL ND ND
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
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: 06/22/2020 08:39 AM without the written consent of Pace Analytical Services, LLC.
Page 7 of 15

aceAnalytical
www.pecolobs.com
QUALITY CONTROL DATA
Project: Anson LF Stormwater - Monthly
Pace Project No.: 92482046
QC Batch: 548307 Analysis Method: SM 2540D-2011
QC Batch Method: SM 2540D-2011 Analysis Description: 2540D Total Suspended Solids
Laboratory: Pace Analytical Services -Asheville
Associated Lab Samples: 92482046001, 92482046002
METHOD BLANK: 2917239 Matrix: Water
Associated Lab Samples: 92482046001, 92482046002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Suspended Solids mg/L ND 2.5 06/18/20 18:10
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
LABORATORY CONTROL SAMPLE:
2917240
Spike
LCS LCS
% Rec
Parameter
Units
Conc.
Result % Rec
Limits Qualifiers
Total Suspended Solids
mg/L
250
234 93
90-110
SAMPLE DUPLICATE: 2917604
92482148001
Dup
Parameter
Units
Result
Result RPD
Qualifiers
Total Suspended Solids
mg/L
72.2
74.4
3
SAMPLE DUPLICATE: 2917605
92482190001
Dup
Parameter
Units
Result
Result RPD
Qualifiers
Total Suspended Solids
mg/L
ND
ND
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: 06/22/2020 08:39 AM without the written consent of Pace Analytical Services, LLC. Page 8 of 15

a 'b
aceAnalytical
www.pacelabs.com
Project: Anson LF Stormwater - Monthly
Pace Project No.: 92482046
QC Batch: 547967
QC Batch Method: SM 5220D-2011
Associated Lab Samples: 92482046001, 92482046002
METHOD BLANK: 2915629
Associated Lab Samples: 92482046001, 92482046002
Parameter Units
Chemical Oxygen Demand mg/L
QUALITY CONTROL DATA
Analysis Method: SM 5220D-2011
Analysis Description: 5220D COD
Laboratory: Pace Analytical Services -Asheville
Matrix: Water
Blank Reporting
Result Limit Analyzed Qualifiers
ND 25.0 06/18/2017:00
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
LABORATORY CONTROL SAMPLE: 2915630
Spike LCS LCS % Rec
Parameter Units Cone. Result % Rec Limits Qualifiers
Chemical Oxygen Demand mg/L 750 752 100 90-110
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2915631 2915632
MS MSD
92481822001 Spike Spike MS MSD MS MSD % Rec
Parameter Units Result Cone. Cone. Result Result % Rec % Rec Limits RPD Qual
Chemical Oxygen Demand mg/L 18600 100 100 18800 18700 226 113 90-110 1 M1
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2915633 2915634
MS MSD
92481686002 Spike Spike MS MSD MS MSD % Rec
Parameter Units Result Conc. Cone. Result Result % Rec % Rec Limits RPD Qual
Chemical Oxygen Demand mg/L 716 100 100 792 795 77 79 90-110 0 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: 06/22/2020 08:39 AM without the written consent of Pace Analytical Services, LLC.
Page 9 of 15

y
Pace Analytical Services, LLC
aceAnalj6dal ® 9800 Kincey Ave. Suite 100
Huntersville, NC 28078078
www.pacelabs.com [phone]
QUALIFIERS
Project: Anson LF Stormwater - Monthly
Pace Project No.: 92482046
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 TN accredited. Contact your Pace PM for the current list of accredited analytes.
TN -The NELAC Institute.
ANALYTE QUALIFIERS
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: 06/22/2020 08:39 AM without the written consent of Pace Analytical Services, LLC. Page 10 of 15

(�IaceAnalyficalo
www.pacelabs.com
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: Anson LF Stormwater - Monthly
Pace Project No.: 92482046
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Analytical
Lab ID
Sample ID
QC Batch Method
QC Batch
Analytical Method
Batch
92482046001
Outfall 3
EPA 1664B
548481
92482046003
Outfall 1
EPA 1664E
548481
92482046001
Outfall 3
SM 9222D-2006
547605
SM
9222D-2006
547607
92482046002
Outfall 4
SM 9222D-2006
547605
SM
9222D-2006
547607
92482046001
Outfall 3
SM 254OD-2011
548307
92482046002
Outfall 4
SM 254OD-2011
548307
92482046001
Outfall 3
SM 5220D-2011
547967
SM
5220D-2011
548350
92482046002
Outfall 4
SM 5220D-2011
547967
SM
5220D-2011
548350
Date: 06/22/2020 08:39 AM
y
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 11 of 15

Document Name:
Document Revised: February 7, 2018
m
20kvlytical
Sample Condition Upon Recel t(SCUR)
Page 1 of 2
Issuing Authority:
_
Document No,:
r
F-CAR-CS-033-Rev.06
Pace Carolinas Quality Office
Laboratory receiving samples:
Asheville ❑ Eden❑ Greenwood ❑ Huntersville Raleigh[] Mechanicsville[]
Simple Condition Client Name:Upon Receipt Project #: Wad# ' 94482-046
Courier:
❑ Commercial
Custody Seal Present?
WIce x ❑U d []Other: ❑Client II II' �'ll (�I' �I II:I �II
/(, 1482046
❑Yes ❑ftl'o seals Intact? ❑Yes f'
Packing Material: []Bubble Wrap ❑Bubble Bags ® one Other
Thermometer: Type of Ice:} et ❑Blue
❑IR Gun ID: 92T061
IsCooler Temp ('C): 5.Correction Factor: Add/Subtract ('C) +0,1
Cooler Temp Corrected ('C)t ISUSDA Regulated Soil ( /A, water sample)
Did samples originate in a quarantine zone within the United States: CA, NY, or SC (check maps)?
Date/Initlels Person Examining Contents:
Biological TissueF zen?
[]None Yes ❑No [� /A
Temp should be above freezing to 6'C
❑Samples out of temp criteria. Samples on Ice, cooling process
has begun
Did samples originate from a foreign source (internationally,
n-ludino Ilawall and PnPrrn Rienli rlYes i-1No
Comments/Discre anc :
Chain ofCustod Present?
s ❑No
N/A
1,
Samples Arrlved within Hold Times
N4 QNq
N A
2,
Short Hold Time Analysis (<72 hr.)?
dies No
N A
3,
Rush Turn Around Time Requested?
ClYe, M4
❑N/A
4.
Sufficient Volume?
[]No
❑N A
S.
Correct Containers Used?
-Pace Containers Used?
[]No
es No
❑N/A
❑N A
6.
Containers Intact?
N/A
7.
Dissolved analysis: Samples Field filtered?
ElvesJ I-JNo
A
8.
Samnia Labels Match COC?
-Includes Date/Time/ID/Analysis Matrix:
s r7lNo
N A
9.
Heads ace in VOA Vials (>5-6mm)?
Yes ❑No
/
10.
Trip Blank Present?
Trip Blank Custody Seats Present?
❑Yes ❑No
Yes []NO
QA
ElN/A
COMMENTS/SAMPLE DISCREPANCY
Person contacted:
Project Manager SCURF Review: IA f/� I ?D
Project Manager SRF Review: 1`1V V 1
Field Data Required? ❑Yes [:]No
IotID of
Date/Time; 6 t ii.��. F/I
Date: l 0 — 1 ']
Date: Lo —I V1 --' 2Ow
Page 12 of 15

2
3
4
5
9
10
12
Document —No..-
*Check mark top half of box If pH and/or dechlorination is
verified and within the acceptance range for preservation
samples.
Exceptions: VOA, Coliform, TOC, Oil and Grease, DRO/BD35 (water) DOC, LLHg
"Bottom half of box is to list number of bottle
Document Revised: February 712D18
Page l of 2
Issuing Authority:
Pace Carolinas Quallty Office
z2 Z ` Q O. ii. C ¢ a
Q
V V N
8i ;z2 V = a ^�
> > C Z Z l7 Q " C (� 1� Pet NO CL L Z M Q z Y t7 Z 2 $ W
u u u = N 2 'O C V V1 11VV E `. 0 V g M _ N ,
N TS V -}W� u V W _ N i Q (N� O 4 '�'� N y ? 1E�i
a i A _d a a d a $i E 2 '" d > a 2 o c
E ;a E of E E o E Q J a > O O pQ $ W E a
ti tn
N T V '^ ryvi �^ = E ref E E E E m + E J a yy� E
7 ' , rl N N O N Q
a ' E E E J
ro m m m oa � rG fn ppz�� d '� 'a N o
Q
f
1
pH Adjustment Log for Preserved Samples
ID Type of preservative pH upon receipt Data preservation ad usted 1 Tlme preservation Amount of Preservative
adjusted lotq
added
Note: Whenever there Is a dlscrepanty affecting North Carolina compliance samples, a copy of this form will be sent to the North Carolina
Out of hold, Incorrect preservative, out of temp, Incorrect containers.
Page 13 of 15

PkMnalytical "
Sample Receiving Non -Conformance Form (NCF)
Date: Evaluated by.
G' ZQ ct Y)4 L • Affix Workorder/Login Label Here or List Pace
Client: M Workorder Number or MTJL Log -in Number
Here
q (e) Ln
1. If Chain -of -Custody (COC) is not received: contact client and if necessary, fill out a COC and indicate that it was filled out by
lab personnel Note issues on this NCF.
7 if rnr is incmmnlete. check applicable issues below and add details where appropriate:
Collection date/time missing or
Analyses or analytes: missing or
Samples listed on COC do not match samples
incorrect
clarification needed
received (missing, additional, etc.
Sample IN on COC do not
match sample labels
Required trip blanks were not received
Required signatures are missing
Comments/Details/Other Issues not listed above: sl
.1 q:%Mnle intenrity issues: check applicable issues below and add details where appropriate:
Samples: Condition needs to be brought to
Samples: Past holding time
lab ersonnel's attention details below
Preservation: Improper
Temperature: not within acceptance criteria (typically
Samples: Not field filtered
Containers: Broken or compromised
0.6C
Samples: Insufficient volume
received
Containers: Incorrect
Temperature: Samples arrived frozen
Samples: Cooler damaged or
Custody Seals: Missing or compromised on
compromised
samples, trip blanks or coolers
Vials received with improper heads ace
Samples: contain chlorine or
sulfides
I Packing Material: Insufficient/Improper
Other:
Comments/Details:
4. if Sam les not preserved properly and Sample Receiving adjusts pH, add details below:
Sample ID:
Date/Time:
Amount/type pres added:
Preserved by:
Initial and Final H:
Lot # of pres added:
Sample ID:
Date/Time:
Amount/type pres added:
Preserved by:
I Initial and Final H:
Lot # of pres added:
Sample ID:
Date/Time:
Amount/typa res added:
Preserved b :
Initial and Final H:
Lot #of pres added:
5. Client Contact: If client is contacted for any issue listed above, fill in details below:
Client: I Contactedper:
F-ALL-C-011-rev.00, O5Jul2018
Page 14 of 15

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