NC0026271_Regional Office Historical File Pre 2018 (54)

OPNORTH CAROLINA
DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
DIVISION OF WATER QUALITY
LABORATORY CERTIFICATION _
Application for Field Parameter
Environmental Laboratory Certification
Form 4200- field application October 2001
INSTRUCTIONS: This application is only one part of the certification process; completing and submitting an application does not
constitute certification: Please complete all applicable parts of this form using a typewriter, computer, or print legibly in ink.
To apply for Field Parameter Laboratory Certification, return the original and one copy of this application to:
Mr. James W. Meyer Q
ENR/DWQ Laboratory Section
Mail Service Center Raleigh,
y y yA
Raleigh, NC 27699-1623
For additional information; -;contact the Laboratory Certification program office:
Telephone: [phone] X 207 AUG 17 2004
Fax: [phone]
E-Mail: [e-mail] DVQ
Program Home -a e:. www..esb.enr--.state.nc.us/lab/cert.htm or dw lab.or 9 P g- q g LABORATORY SECTION.. -..,....,-
Municipal, Industrial and Other Facilities should fill out only -Sections A, C and provide a -signature in Section.. D. ...`
Commercial Facilities must supply all applicable information in Section A, additional identification of all regulated
facilities in Section B, and signatures required in Section D.
Section A: Facility and Contact. .lnforination _
Facility Name or Commercial Management Company Name ZGwlJ OX 1,4y& /19 Ul
Contact Person ;6,-Z."qfj �5/QD C-_S Telephone # ext (Y2�) 4 3 a• 5_2Y U
EPA Laboratory Code /1r C- O /a ]"i, e'j FAX # (�Qz?1\ 3, _X 5%.7 0
Laborato4%upervisor !-740 i; S \
Laboratory Supervisor/Operator's Certificate Number 14946 GradefTvpe of Certificate(s) 6 •� O
If not a Certified Laboratory experience
Operator, please provide Education level and/or Laboratoexperience
A11i1fii
Laboratory Supervisor E-Mail Address: � 11 t? C ya�lou `�•r Telephone #, ext./ r��-`d 1� 3L-
Facility Address 3V-41 ml,-f6�nj �"a I�VICL,� N .� • �)i ���
Mailinq Address 7 dip 4✓ z_ %t, Luitswu(_ fc /U • e • Z ��,}� J
City `7 Z-0 &'y 1/i LL V_- State Zip
1-1
For a municfpal/ii dustrial facility certification only, please list-NPDES permit nuffi-ber(s)-_and county.location below:
Additional sheets maybe attached -if necessary. Commerciial applicants please fill out Section,B.
NPDES # COUNTY
NPDES # COUNTY
NPDES # -' COUNTY

W—
Section
B _ Commercial Client Contact Information (Municipal/Industrial applicants - proceed.:to Section-C)_
Please list below information regarding current clients serviced by your company's management program:
V/Lc. f- LLJ L J P
A)Cao 2627 /
G,/GJ _1.i1__
Facility Street Address � T�f � / -J1 (r o 11) Z-N . City/State 1 0.nsV1LL e.1 N C Zin
Facility Name
NPDES #PC�o'414917Tvpe/Grade of Plant
Facility Street Address./. PU 6e-6vT- MJLL� tL'b
City/State
'e.Q-G'4 u ems+7'"D 4.2,a'p,
lZ 12
Atcoo $ 4to qL
svNS A,a)- , N C-
Facility Name NPDES # Type/Grade of Plant
Facility Street Address City/State Zip
X
Him
Facility
Name
NPDES #
Type/Grade of Plant
Facility
Street Address
City/State
Zip
Facility
Name
NPDES #
Type/Grade of Plant
Facility
Street Address
City/State
Zip
Facility
Name
NPDES #
Type/Grade of Plant
Facility
Street Address
City/State
Zip
Facility
Name
NPDES #
Type/Grade of Plant
Facility
Street Address
City/State
Zin
Facility
Name
NPDES #
Tvpe/Grade of Plant
Facility
Street Address
City/State
Zip
THIS SECTION MAYBE COPIED AS NECESSARY. PLEASE NUMBER THIS AND ADDITIONAL PHOTOCOPIED PAGES
PAGE ----- OF ------

((Types of Samples Processed (Check all that apply)
Wastewater Effluent (Domestic) ti Storm Water
Wastewater Effluent (Industrial) IT Reclaimed Water
�i Groundwater [Y Pretreatment
Lf Surface Water ❑ Other (please specify)
i7/Public Water Supply
(2) Circle, or write in, the method used for each requested analytical parameter, and indicate the laboratory's lower reporting
limit with units of measure.
Analytical Parameter
-
EPA
Methods
StanAard Methods
18t 19�' 20" Edition
Other
Methods
Lower Reporting
Limit
Concentration
(include units)
' :-OFFICE
USE .-
".ONLY- = :
Specific Conductance
120.1
2510 B
Dissolved Oxygen
360.2
4500-0 C
360.1
4500-0 G
-pH .: . - .
150A-
-_-4500H+ -B.
Residue, Settleable
160.5
2540 F
= `
Chlorine, Total Residu
330.1
4500CI B
- D�a
Z u is
330.2
4500CI C
330.3
4500CI D
330.4
4500CI F
330.5
4500CI G
Cemperature
170.1
2550 B
(3) Equipment: Please list equipment available to perform the selected analyses:
Analytical Parameter
Equipment
office Use
V7' 0"4T
J
(4) Quality Control Program - the following must be available upon request.
(a)' Data pertinent to each analysis must be maintained for five years. Certified data must consist of date collected,
time collected, sample site, sample collector, and sample analysis time. The field benchsheets must provide a
space for the signature or initials of the analyst, and proper units of measure for all analyses.
(b) A record of instrument calibration where applicable, must be filed in an orderly manner so as to be readily
available for inspection upon request.
(c) A copy of each approved analytical procedure must be available to each analyst.
(d) Each facility must have glassware, chemicals, supplies, equipment, and a source of distilled or deionized water
that will meet the minimum criteria of the approved methodologies.
(e) Evidence of participation in an annual quality assurance study.

D Authorized'
This statement certifies that the information in this application is truthful and accurate, and that the applicant is aware of
all regulations regarding the Quality Ass-urance requirements of Laboratory Certification.
Z' ,
Date: Application Received:
Invoice-#
Check-#
Application Process Completed:
NC Lab. Certification Number
Date Certification Isisued
Office Use Only:
nat.- .Y111 / zoo
Revised 9/28/01