NCG060264_DMR_20200224

M►
North Carolina Department of Environment
Division of Water Quality
Attn: DWR Central Files
1617 Mail Services Center
Raleigh,NC 27699-1617
Subject: NPDES General Permit: NCG060264
The Procter and Gamble Manufacturing Company(P&G)
Greensboro Personal Health Care(GBO PHC)
100 Swing Road, Greensboro,North Carolina 27409
Discharge Monitoring Report
To Whom It May Concern:
Attached,please find Procter and Gamble's submission of:
• Semi-Annual Storm Water Discharge Monitoring Report for reporting period Jan. 1 to
July 1, 2020
• Storm Water Feb. 6, 2020 analytical report for Jan 1 to July 1, 2020 reporting period
The report for Feb. 6, 2020 found all parameters below storm water benchmarks. Should you
have any questions on this report please contact the site Health, Safety and Environmental
Technical Contact, Tracy Davis at(336) 315-6903 or [e-mail].
►fir-.�,��� e►-t'+
Sincerely, MAR 0 2 Cu1U
CENTRAL FILES
DWR SECTION
• ze7/2 V242Z-L)
Ron Matusiak Date
GBO PHC Plant Manager

•
STORMWATER DISCHARGE MONITORING REPORT
for North Carolina Division of Energy, Mineral and Land Resources General Permit No. NCG060000
Date submitted Feb.6,2020
CERTIFICATE OF COVERAGE NO. NCG06 0 2 6 4 SAMPLE COLLECTION YEAR 2020
FACILITY NAME Procter and Gamble —
COUNTY Guilford SAMPLE PERIOD n Jan-June —
July-Dec
PERSON COLLECTING SAMPLES Tracy Davis or n Monthly5 (month)
LABORATORY Pace Analytical Services Lab Cert.# 12 DISCHARGING TO CLASS ORW HQW Trout I IPNA
❑Zero-flow nWater Supply ❑SA
nOther N/A
FACILITY ACTIVITIES INCLUDE (check all that apply):
n use/process meats n use animal fats/byproducts
0 PLEASE REMEMBER TO SIGN ON THE REVERSE 4BAR 0 ii 2 2020
Part A: Stormwater Benchmarks and MonitoriniAiatAtL Fit, a Total event rainfall2 0.2 or n No discharge this period'
OutfaII No. Date Sample TSS, pK,ON COD, Oil and Grease, Fec?I Coliform, Enterococci,
Collected,mo/dd/yr mg/L Standard units mg/L mg/L Colonies per 100 ml Colonies per 100 ml
Benchmark - 100 or 504 Within 6.0—9.0 120 30 10001 5001
Parameter Code - C0530 00400 00340 00556 31616 61211
02-06-2020 17.0 6.0 34.5 N.D. 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 1, identifying the especially sensitive receiving water classifications where the more protective benchmark applies.
'Monthly sampling(instead of semi-annual) must begin with the second consecutive benchmark exceedance for the same parameter at the same outfall.
Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new oil per month? n yes n no (if yes, complete Part B)
Permit Date: 11/1/2018-05/31/2021 SWU-249, Last Revised 11/5/2018
Page 1 of 2

Part B: Vehicle Maintenance Area Monitoring Results: only for facilities averaging >55 gal of new motor oil/month.
Outfall No. Date Sample Collected 24-hour rainfall amount, New Motor Oil or Non-Polar O&G/Total Total Suspended Solids
(mo/dd/yr) Inches2 Hydraulic Oil Usage Petroleum Hydrocarbons
Benchmarks - - - 15 mg/L 100 mg/L or 50 mg/L4
Parameter Code - 46529 NCOIL 00552 C0530
Footnotes from Part A also apply to Part B
*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 Q
IF YES, HAVE YOU CONTACTED THE DEMLR REGIONAL OFFICE? YES ❑ NO ❑
REGIONAL OFFICE CONTACT NAME:
Mail an original 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
of"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:
"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."
Signature of Permittee Date
Permit Date: 11/1/2018-05/31/2021 SWU-249, Last Revised 11/5/2018
Page 2 of 2

Pace Analytical Services,LLC
9800 Kincey Ave. Suite 100
aceAnalytical Huntersville,NC 28078
www.pacalabs.com [phone]
February 19, 2020
Mr. Tracy Davis
Procter and Gamble
100 Swing Road
Greensboro, NC 27409
RE: Project: Stormwater
Pace Project No.: 92464075
Dear Mr. Davis:
Enclosed are the analytical results for sample(s) received by the laboratory on February 06, 2020.
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,--��.
Matthew Brainard
[e-mail]
[phone]
Project Manager
Enclosures
AL ,
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
e° ' without the written consent of Pace Analytical Services,LLC. Page 1 of 12

Pace Analytical Services,LLC
9800 Kincey Ave. Suite 100
aceAnalytical Huntersville,NC 28078
www.pacelabs.com [phone]
i
I
CERTIFICATIONS
Project: Stormwater
Pace Project No.: 92464075
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#:99030001
Massachusetts Certification#: M-NC030 VirginiaNELAP Certification#: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 12

• Pace Analytical Services,LLC
aceAnalytical 9800 Kinsey Ave. Suite 100
Huntersville,NC 28078
www.pacelabs.corn [phone]
SAMPLE ANALYTE COUNT
Project: Stormwater
Pace Project No.: 92464075
Analytes
Lab ID Sample ID Method Analysts Reported Laboratory
92464075001 Water Samples EPA 1664E WAM 1 PASI-C
SM 2540D-2011 CJL 1 PASI-A
SM 5220D-2011 LMS1 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 12

Pace Analytical Services,LLC
°� 9800 Kincey Ave. Suite 100
aceAnalytical Huntersville,NC 28078
www.pacelabs.com [phone]
1
ANALYTICAL RESULTS
Project: Stormwater
Pace Project No.: 92464075
Sample: Water Samples Lab ID: 92464075001 Collected: 02/06/20 08:35 Received: 02/06/20 10:40 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
HEM,Oil and Grease Analytical Method:EPA 1664B
c 5.0 1 02/19/20 09:21 M1
2540D Total Suspended Solids Analytical Method:SM 2540D-2011
Total Suspended Solids 17.0 mg/L 5.0 1 02/12/20 16:28
5220D COD Analytical Method:SM 5220D-2011 Preparation Method:SM 5220D-2011
Chemical Oxygen Demand ' 34.5 mg/L 25.0 1 02/13/20 11:55 02/14/20 10:13
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
Date:02/19/2020 03:42 PM without the written consent of Pace Analytical Services,LLC. Page 4 of 12

Pace Analytical Services,LLC
ace Analytical 9800 KinceyAve. Suite 100
Huntersville,NC 28078
www.pacelabs,com [phone]
1
QUALITY CONTROL DATA
Project: Stormwater
Pace Project No.: 92464075
QC Batch: 525861 Analysis Method: EPA 1664B
QC Batch Method: EPA 1664B Analysis Description: 1664 HEM,Oil and Grease
Associated Lab Samples: 92464075001
METHOD BLANK: 2810614 Matrix: Water
Associated Lab Samples: 92464075001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Oil and Grease mg/L ND 5.0 02/19/20 09:21
LABORATORY CONTROL SAMPLE: 2810615
Spike LCS LCS %Rec
Parameter Units Conc. Result %Rec Limits Qualifiers
Oil and Grease mg/L 40 34.4 86 78-114
MATRIX SPIKE SAMPLE: 2810616
92464075001 Spike MS MS %Rec
Parameter Units Result Conc. Result %Rec Limits Qualifiers
Oil and Grease mg/L ND 40 12.1 28 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:02/19/2020 03:42 PM without the written consent of Pace Analytical Services,LLC. Page 5 of 12

Pace Analytical Services,LLC •
9800 Kincey Ave. Suite 100
ace Analytical Huntersville,NC 28078
www.pacelabs.com [phone]
QUALITY CONTROL DATA
Project: Stormwater
Pace Project No.: 92464075
QC Batch: 524818 Analysis Method: SM 2540D-2011
QC Batch Method: SM 2540D-2011 Analysis Description: 2540D Total Suspended Solids
Associated Lab Samples: 92464075001
METHOD BLANK: 2805226 Matrix: Water
Associated Lab Samples: 92464075001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Suspended Solids mg/L ND 2.5 02/12/20 16:24
LABORATORY CONTROL SAMPLE: 2805227
Spike LCS LCS %Rec
Parameter Units Conc. Result %Rec Limits Qualifiers
Total Suspended Solids mg/L 250 240 96 90-110
SAMPLE DUPLICATE: 2805228
92464052001 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 65.0 79.0 19
SAMPLE DUPLICATE: 2805229
92464084004 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 362 444 20
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:02/19/2020 03:42 PM without the written consent of Pace Analytical Services,LLC. Page 6 of 12

Pace Analytical Services,LLC
9800 Kincey Ave.eAnalytical Huntersville,NC 28078
www.pacelabs.com [phone]
i
QUALITY CONTROL DATA
Project: Stormwater
Pace Project No.: 92464075
QC Batch: 524948 Analysis Method: SM 5220D-2011
QC Batch Method: SM 5220D-2011 Analysis Description: 5220D COD
Associated Lab Samples: 92464075001
METHOD BLANK: 2805841 Matrix: Water
Associated Lab Samples: 92464075001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Chemical Oxygen Demand mg/L ND 25.0 02/14/20 10:06
LABORATORY CONTROL SAMPLE: 2805842
Spike LCS LCS %Rec
Parameter Units Conc. Result %Rec Limits Qualifiers
Chemical Oxygen Demand mg/L 750 763 102 90-110
MATRIX SPIKE&MATRIX SPIKE DUPLICATE: 2805843 2805844
MS MSD
2628734001 Spike Spike MS MSD MS MSD %Rec
Parameter Units Result Conc. Conc. Result Result %Rec %Rec Limits RPD Qual
Chemical Oxygen Demand mg/L 394 100 100 472 470 78 76 90-110 0 M1
MATRIX SPIKE&MATRIX SPIKE DUPLICATE: 2805845 2805846
MS MSD
2628774001 Spike Spike MS MSD MS MSD %Rec
Parameter Units Result Conc. Conc. Result Result %Rec %Rec Limits RPD Qual
Chemical Oxygen Demand mg/L 286 100 100 389 383 104 97 90-110 2
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:02/19/2020 03:42 PM without the written consent of Pace Analytical Services,LLC. Page 7 of 12

Pace Analytical Services,LLC
aceAg 9800 Kincey Ave. Suite 100
ralyti al Huntersville,NC 28078
wwwpacelabs.com [phone]
QUALIFIERS
Project: Stormwater
Pace Project No.: 92464075
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 TNI accredited.Contact your Pace PM for the current list of accredited analytes.
TNI-The NELAC Institute.
LABORATORIES
PASI-A Pace Analytical Services-Asheville
PASI-C Pace Analytical Services-Charlotte
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:02/19/2020 03:42 PM without the written consent of Pace Analytical Services,LLC. Page 8 of 12

• Pace Analytical Services,LLC
9800 Kincey Ave. Suite 100
,,tace Analytical Huntersville,NC 28078
www.pacalabs.com [phone]
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: Stormwater
Pace Project No.: 92464075
Analytical
Lab ID Sample ID QC Batch Method QC Batch Analytical Method Batch
92464075001 Water Samples EPA 1664E 525861
92464075001 Water Samples SM 2540D-2011 524818
92464075001 Water Samples SM 5220D-2011 524948 SM 5220D-2011 525199
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
Date:02/19/2020 03:42 PM without the written consent of Pace Analytical Services,LLC. Page 9 of 12

Document Name: Document Revised:February 7,2018
Sample Condition Upon Recelpt(SCUR) Page 1 of 2
aceAnalyticar Document No.: Issuing Authority:
i F-CAR-CS-033•Rev.06 Pace Carolinas Quality Office
Laboratory receiving samples:
Asheville❑ Eden❑ Greenwood❑ Huntersvil Raleigh❑ MechanicsvilleD
Sample Condition Client Name:ece ,,-~" Project#: WO 92464075
Upon Receipt
Courier: ❑Fed Ex ❑UPS ❑LISPS ❑Client 111111 1111111 111111
Ill
❑Commercial J]Pace ❑Other: 92464075
Custody Seal Present? Dyes o Seals Intact? Dyes "IfN-o il-_ / ->
Date/Initials Person Examining Contents: rr �''r:----, /
Packing Material: ❑Bubble Wrap 28-ubble Bags ['None ❑ Other Biological Tissue Frozen?
Thermometer: Dyes ❑No 11N/A
❑IR Gun ID 92T058 Type of Ice: EICket OBlue ONone
Cooler Temp('C): -Th Correction Factor:Add/Subtract(°C) 0.0°C Temp should be above freezing to VC
Cooler Temp Corrected{'C): °Samples out of temp criteria.Samples on ice,cooling process
has begun
USDA Regulated Soll ( N/A,water sample)
Did samples originate in a quarantine zone within the United States:CA,NY,or SC(check maps)? Did samples originate from a foreign source(internationally,
Oyes ❑No including Hawaii and Puerto Rico)?Oyes °No
Comments/Discrepancy:
Chain of Custody Present? OTe's ❑No ON/A 1.
Samples Arrived within Hold Time? es ❑No ON/A 2.
Short Hold Time Analysis(<72 hr.)? Oyes 6io ON/A 3.
Rush Turn Around Time Requested? Oyes 'QQNo ON/A 4.
Sufficient Volume? Dies ONo ON/A 5.
Correct Containers Used? pris ONo ON/A 6.
-Pace Containers Used? Elves ONO ON/A
Containers Intact? Elces ONo ON/A 7.
Dissolved analysis:Samples Field Filtered? Oyes ONo uN/A 8.
Sample Labels Match COC? ges ONo ON/A 9.
-Includes Date/Time/ID/Analysis Matrix: "' * !
Headspace in VOA Vials(>5-6mm)? Des ONo N/A 10,
Trip Blank Present? Oyes ONo -JN/A 11.
Trip Blank Custody Seals Present? Des ONo O/N/A
COMMENTS/SAMPLE DISCREPANCY Field Data Required? Des °No
lot ID of split containers:
CLIENT NOTIFICATION/RESOtUTION
Person contacted: Date/Time:
7
Project Manager SCURF Review: ' Date:
Project Manager SRF Review: €. x Date:
Page 10 of 12

Document Name: Document Revised:February 7,2018
Sample Condition Upon Receipt(SCUR) Page 1 of 2
i aceAnaiytical Document No.: Issuing Authority:
F-CAR-CS-033-Rev,06 Pace Carolinas Quality Office
*Check mark top half of box if pH and/or dechlorination is Project# , 10# a2464O?t6
verified and within the acceptance range for preservation
v/ Due Date: 02/20/20
samples. PM: MN
Exceptions:VOA,Coliform,TOC,Oil and Grease,DRO/5015(water)DOC,LLHg CLIENT: 82-P&G
**Bottom half of box is to list number of bottle i
2 '. 2 z
` x V .1) n —
z
2 z z = U n a. ._ Z Z O .ao m .g ro
y W V p
V V « W N V 7< Q Z 'fit a •,Q" 1 Z 2 N
m tl m 2 n m n '" v v b n Si z 2 ` y n 2 Z a '^ v
N N w Q
v A H
G Q N 0 V 2 A v p n C O n' ` '"� ? t�.f = N N n > .y..
c c c Q 2 g O `^ E Z Dry - 8 o a N x c c a.
c i Z N 2 avy� c tJ n`�i i Q n ni a n a Z 2 V
.+ u •. _ u .,, v L 2 E 2 -w 2 L r a u _
A A ra X3 ' 2 o a -0 E a E N < < /r.c Q M a. m E c E
Ja. J J d a d J 6J. E Q Q Q Q J ~ O O J J J V1 Q
uE o ppE a, E of E E y `a `v o oEE .`cil E E E E E E of o E E
N ° O z N 2 r, N n ... v7 I N g l� D O O > H �T 0 0 0
.. IN In .. ,-, N ., N .. N Q q Q O 4 ti N NQ p" pi Q
3 O 3 2 N V 5 � I g {n N eF S i- g G Y * r. 4 17 `6 6
E V OI N .-1 Mp, V O .-1 N M rl M 01 OI Oi Q U� VI N g
— am m iO aN m 6 tL V .1' 1 l U` t4 8ty U' t, 2�ry 3 ti 6
Via, m m d Q ¢ Q Q Q G > > C > > v�i �vS eq 4 ?
V.. \\\\\\\\ \.\ .
1 \ ;
2 \ \\\ \:\\,\\, ,
3 \ \`
\\\\\\\\\ '‘\\\\\.. '\* '' 'N'
4 \\
S \
7 \
\\\ '.\\\\\\. .. .
8 \ \\
6 \
1
: \\\\\ \\ ,
9 \
10
11 \ \
12 \ \\\ \\\\.
pH Adjustment Log for Preserved Samples
Sample ID Type of Preservative pH upon receipt Date preservation adjusted Time preservation Amount of Preservative tot N
adjusted added
Note: Whenever there is a discrepancy affecting North Carolina compliance samples,a copy of this form will be sent to the North Carolina DEHNR Certification Office(i.e.
Out of hold,incorrect preservative,out of temp,incorrect containers.
Page 11 of 12

CHAIN-OF-CUSTODY /Analytical Request Document
eAfrelytical. The Chain-of-Custody is a LEGAL DOCUMENT.All relevant fields must be completed accurately.
•arr wet t r l:t0•
Section A Section B Section C
Required Client Information: Required Proje.:t Information: Invoice Information: Page: 1 Of 1
Company. Procter and Gamble Report To: Tracy Oars Attention.
Address_ 1C0 Swmg Road Copy To. Company Name.
Greensboro,NC 27409 Address: Regulatory Agency
Email: davis.t.26i pg.com Purchase Order#: Pace Quote;
Phone- 919-619.5501 IFax Project Name: Stormwater Pace Project Manager [e-mail]. State!Location
Reques:ed Due Date: Project#: Pace Profile#: 8440.2 NC
Requested Analysis Filtered 0Y/N)
a Z
Mrsaix Cote o COLLECTED 2 Preservatives >-
_
Drmkrngwafer DIN v` O W
water WT $ V U 2
Waste Water W W to 'CLa
Product P > C Z
SAMPLE ID SealSoiw SI
r t9 START END z . a
One Character per box. W n WP W W & z 01 4
(A-2,0.9/,-) au AROther on 0 EL tCS F a re d
t
Sample Ids must be unique Inure rs E .w, u F < n = ON m C 7 _
¢ a a O _ rn f c Q rn ,t
r 4 Q Q O C N z U CO W m
et us DATE TIME DATE TIME to e, 0 2 x I z z M o I`-- 0 0
r
2 .f r4 - 2_ ') cif CY aR(7- Y.;sa ��1 !"iS.0 t �C
rA
3 } :,r L+' n �t U
�.L.) �. ?,,:c �'•›S-f, -1,�4. d..,A ) X X .
a 1 ''FC )i u. -s5.1 I A X
5
6
7
8
9
10
11
12
ADOmONAL COMMENTS RELINQUISHED BY/AFFILIATION DATE TIME ACCEPTED BY I AFFILIATION DATE TIME SAMPLE CONDITIONS
r -,I� �fie. 1L1�I h�r `— { Gw�A 03i
7 n 10tf4
��
i
SAMPLER NAME AND SIGNATURE
CO U o
PRINT Name of SAMPLER:CD
j� c n
ha SIGNATURE of SAMPLER: ^� I DATE Signed: D i j w Z A o z E r,z
tJ
1