WQ0014046_Monitoring - 11-2020_20201208

SUBMIT FORM ON YELLOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
AGILITY INFORMATION Please Print Clearly or Type
acility Name: Tpl,liln n �
ermit Name (if different):
acility Address: � rJ5 Cj
NC " 151D5 County v . jC
intact Person. .1 I� Telephone#:
ell Location/Site Name:1(Wn _ �I VjuSTP No. of wells to be sampled: 4
DEPARTMENT OF ENVIRONMENT 3 NATURAL RESOURCES
OF WATER QUALITY -INFORMATION PROCESSING UNIT
rVISION
617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
PFR,M�I Nu�mber:
Expiration Date: I Z SI Z0
Non Aa7P I1-AD4 (0
UIC
NPDES
Other
TYPE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon
❑ Remediation: Infiltration Gallery
fr� Spray Field
❑ Remediation:
❑ Rotary Distributor
❑ Land Application of Sludge
❑ Water Source Heat Pump
❑ Other:
..rIrnr%r r.rr.
TELL ID NUMBER (from Permit): ChyJ
Date sample collected: I� I y I2V
FIELD ANALYSES:
If WELL
WAS
tell Depth: ft.
Well Diameter: of in.
pH LC •C6 units Temp. 15. Z °C
DRY at
epth to Water Level: I ft. below measuring point
Screened Interval: ft. to .
ft
Spec. Cond. �� µMhos
t ime of
easuring Point is _ft. above land surface
_
Relative M.P. Elevation: ft.
Odor ow—,
sampling,
check
)lume of water pumped/bailed before sampling:
gallons
Appearance Cl ear
here:
imp es for meta Is -were coected unfiltered- YES
NO and field acidified: ❑YES NO
late sample analyzed: I I a,— 1 1 11I 1 Laboratory Name: MeIr'*ck —Moc-
ARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD mg/1 Nitrite (NO.) as N mg/I Pb - Lead
Coliform: MF Fecal ' Co I /100m1 Nitrate (NO3) as N n.Lkq mg/1 Zn - Zinc
Coliform: MF Total /100ml Phosphorus: Total as P b.0Li (p mg/I
Certification No. ISD
mg/1
mg/I
(Note: Use MPN method for highly turbid samples)
Orthophosphate
mg/I
Other (Specify Compounds and CorwitGn Units):
Dissolved Solids: Total "lq mg/I
-
Al -Aluminum
mg/I
pH (when analyzed) C0 .Q units
Ba - Barium
mg/I
TOC ISO mg/1
—mg/1
c
�
Ca -Calcium
mg/I
,
Chloride I S
I
Cd - Cadmium
mg/I
Arsenic mg/I
Or;
Chromium: Total
mg/I
Grease and Oils mg/I
c
Cu -Copper
mg/I
ORGANICS: (by GC, GC/MS, HPLC)
Phenol mg/1
ry
o
Fe - Iron
mg/I
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate mg/I
Hg - Mercury
mg/I
Report Attached? 04 Yes (1) ❑ No (0)
Specific Conductance µMhos
K - Potassium
mg/I
VOC method #
Total Ammonia mg/I
Mg - Magnesium
mg/1
method #
(Ammonia Nitrogen; NH3as N, Ammonia Nitrogen, Total)
Mn -Manganese
mg/I
method #
TKN as N mg/I
Ni - Nickel
mg/1
method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs:
Permittee (or
GW-59
Please print or type
mg/L Effluent Total VOCs:
of Permdtee (or Authorized Aoentl
mg/L VOC Removal%
;Date)
Rev. 1/2007

cr�ti.->v.a � c l;�r►>r,(�����r [tr?F�c�trr u�c�Et,�r !'ct-1�,fi /iW�,,.0a1 yogic
Subrrtit une err"h nrr•,it„ity nrrrml:j-ith GlG-?9
Enter date monitoring results were due. ( l '.0 W11� this monitoring report (GW-59 and GW-59A) be submitted after the established due date?
-- - •'yam•• 1.. ,mil mauon missing on the GW-59 report forms?
IF the answer to question I or 2 is "YE", ist in the spec rovi;iee below the well identification numbers) and
explain the problems encountered in obtainin the requirod information.
YES
YES
3 1 k re any of the monitor wells in need of repair or maintenance (damaged caun
identification plate, area overgrown, etc.)" if the ansiper. is "Yrs", crrdnet the Re ion rl !:)+r unloEked or missing cap, missing I y'I•
8 icc j r �uidunce.
Are any monitored constituents equal to or above the estahiicj��d standards? ------- lithe answer to question 4 is "NO", skip to section 8. -- -
If the answer to question 4 is "YES" list the affected wells individually with constituent(s) and concentration(s)
exceeding standards in t;,e space provided below. -
For the constituents identified in question 4 above, have standards been exceeded previously for the
same constituent(s) in the same well(s) in the last two years? YES NO
If the answer to question 5 is "NO", skip to section 8. _
If the answer to question 5 is "YES", list in the space provided below, each well with constituent(s) exceeding
standards, concentration(s) reported, and sample collection date for each occurrence (for the last two years).
6 Are the monitoring wells listed in section 5 located at or beyond the review boundary?
YES NO
If the answer Is "YES ", a groundwater quality problem maybe occurring. CONTACT THE REGIONAL —
OFFICE IMMEDIATELY FOR GUIDANCE. If the answer is "NO", monitoring wells maybe improperly
located; contact the Regional Office.
Is the permittee implementing previously approved actions required'by the Division involving this YES NO
groundwater quality problem?
:
if the answer to question 7 is "YES", describe those actions in the space provided below. - -
If the answer to question 7 is "NO", contact the Regional Office within 90 days- an evaluation may be
required to determine the impact the waste dts osa/ system is havin w and coin lia
at the revience
boundaries surroundin this facilit . Failure to do so ma sub'ect the ermittee to a Notice of Violation
fines, and/or penalties
8 The person completing this portion (GW-59A) of the monitoring report should sign below and submit this
form with GW-59 forms for required wells to the address provided at the top of the current GW-59 form.
I hereby acknowledge that the above information was evaluated and the information submitted in this
report (C?iance Report GW-59A) is true and complete to the best of my knowledge.
Authorized Agent)
IZINZo
Oate
GAV-59.A 1 _2/3/211113

GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
AGILITY INFORMATION Please Print Clearly or Type
acility Name: TOwn clf p
ermit Name (if different):
ity Address:
SUBMIT FORM ON YELLOW PAPER ONLY
NC Q]C(0 5 County
tact Person: 1>4iiiP hcxjn'ctgs Telephone#: %Ct- ( Oil I- Ir)5�p
Location/Site Name: \Cwn Q-V f��kj J )LAP No. of wells to be sampled: LA
�ARTMENT OF ENVIRONMENT & NATURAL RESOURCES
ISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
7 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
er: Expiration Date:
i 404(o UIC
NNULS Other
TYPE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
Spray Field ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
/ELL ID NUMBER (from Permit): Date sample collected: 1,"y -1() FIELD ANALYSES:
/ell Depth: 33 ft. Well Diameter: a in. pH eV, 1 Z units Temp. 15.a °C
epth to Water Level: 171_ft. below measuring point Screened Interval: ft. to _ft. Spec. Cond. Zp(p µMhos
easuring Point is ft. above land surface Relative M.P. Elevation: ft. Odor tdo
)lume of water pumped/bailed before sampling: fly, gallons Appearance IMAc-
imp es for metals -were -collected- unffltened: 1Z YES - _ -NO- and field acidified: 1kJ YES ❑ NO
late sample analyzed: 1141 ZU - III %%kw Laboratory Name: Miu,im:k -'I-r`c-
ARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD mg/I Nitrite (NO2) as N mg/I Pb - Lead
Coliform: MF Fecal /100ml Nitrate (NO3) as N Q,15 mg/1 Zn - Zinc
Conform: MF Total /100ml Phosphorus: Total as P mg/I
(Note: Use MPN method for highly turbid samples)
Certification No. (QtL?
mg/I
mg/I
Orthophosphate
mg/1
Other (Specify Compounds and Concentration Units):
Dissolved Solids: Total ig mg/I
Al - Aluminum
mg/1
pH (when analyzed) 5.01 units
Ba - Barium
mg/1
TOC 5 N. mg/I
Ca - Calcium
mg/I
Chloride 5.0 mg/1
Cd - Cadmium
mg/I
Arsenic mg/I
Chromium: Total
mg/I
Grease and Oils mg/I
Cu - Copper
mg/I
ORGANICS: (by GC, GC/MS, HPLC)
Phenol mg/I
Fe - Iron
mg/1
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate mg/I
Hg - Mercury
mg/1
Report Attached? 9 Yes (1) ❑ No (0)
Specific Conductance µMhos
K - Potassium
mg/I
VOC . method #
Total Ammonia <� C), I mg/I Mg - Magnesium mg/1
(Ammonia Nitrogen, NH3 as N, Ammonia Nitrogen, Total)
Mn -Manganese mg/1
TKN as N mg/I Ni - Nickel mg/I
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs
p?,C.
Per—m-i ee (or Authorized Agent) Name and Title - Please print or type
GW-59 Rev. 112007
mg/L Effluent Total VOCs:
method #
method #
method #
mg/L VOC Removal%
(Date)
WELL
DRY at
time of
sampling,

G,W-59A (- 4-0,i)>[JANCEN ta.mia i,�'ciz
tlil U/lV(JQ 114 t/
llp•,l
Enter date monitoring results were due. (1 Will this monitoring report (GW-59 and GW-59A) YES
be submitted after the established due date?
r Was any required information missing on the GW-59 report Glrms? --
---- _ _ YES
IF the answer to question 1 or 2 is "YE 3 list n) the spat; �.rovidea below the welt Identification number(sj aand
explain the problems erccuntered in obtainin the rettllirod uVormetion.
3 \ re any of the monitor wells in need of repair or maintenance ((lamaged caging, unlocked or missing cap, missing
identification plate, area overgrown, etc.)? if the answer is "Yes", contact the. Revionul01
T rcc Ji)r ,utdunce.
Are arij monitored constituents equal to or above the estahlisl,ed standards?
!r the answer to question 4 is `NO", skip
If the answer to question 4 is "YES" list the affected wells individually with constituents) and concentration(s) I —
exceeding standards in ti,e space provided below.
5
6
For the constituents Identified in question 4 above
same constituent(s) in the same well(s) in the l, have standards been exceeded previously for the
ast two years? YES NO
If the answer to question 5 is "NO", skip to section 8.
If the answer to question 5 is "YES", list in the space provided below, each well with constituent(s) exceeding
standards, concentration(s) reported, and sample collection date for each occurrence (for the last two years).
Are the monitoring wells listed in section _51o"cated at or beyond the review boundary?
If the answer is ,YES", a groundwater quality problem may be occrring. CONTACT THE REGIONAL
OFFICE IMMEDIATELY FOR GUIDANCE. If the answer is "NO", monuitoring wells maybe improperly
located; contact the Regional Office.
Is the permittee implementing previously approved actions required by the Division involving this
groundwater quality problem?
If the answer to question i is "YES", describe those actions in the spaceprovide
d bebelow.
required -
If the answer to question 7 is "NO", contact the Re ional Office within 90 days; an evaluation may be
boundaries
ies surroundin to determine the im act the waste dis osal s stem is havin at the review and com liance
fines, and/or s�enalties this facilit . Failure to do so may sub"ect the permittee to a Notice of Violation
$ The person completing this portion (GW--59A) of the monitoring report should sign below and submit this
form with GW-59 forms for required wells to the address provided at the top of the current GW-59 form.
I here ck owledge that the above information was evaluated and the information submitted in this
repo Co liancegeporttGGWW-7559A) is true and complete to the best of my knowledge.
Signature of Permittee (or Authorized Agent) - '�' D Zr)
Date
12/812003
YES I NO
YES I NO

SUBMIT FORM ON YF1 LOW PAPER ONLY
GROUNDWATER QUALITY MONITORING:
COMPLIANCE REPORT FORM
FACILITY INFORMATION Please Print Clearly or Type
acility Name: —Fool-) (W S-bian1
'ermit Name (if different):
acility Address:
NC a1 S (p S County 1--f-
tact Person. �- M cx oao", s Telephone#: qtq-(0q1- 1
Location/Site Name:7—ni Lin C ' 5KkL t1 C1J11J-TP No. of wells to be sampled: L•
PARTMENT OF ENVIRONMENT 3 NATURAL RESOURCES
ISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
7 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
ER ber: Expiration Date:
Itsc �` ti � UIC
PDES Other
TYPE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
Spray Field ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
MBER (from Permit): _V—nw t%3 Date sample collected: � � 4
7Depth:35
35 ft. Well Diameter: a in.
ter Level: j ft. below measuring point Screened Interval: ft. to ft.
int is ft. above land surface Relative M.P. Elevation: ft.
ter pumped/bailed before sampling: ► vi gallons
-
e s were -co ecred unfiltered- YES - - -NO - and field acidified: YES ENO
FIELD ANALYSES:
){ 4•y
p (D ro units Temp. Cp 17 p µMhos
Sec. Cond.
Odor ij oNe,
Appearance `PLt t'
If WELL
WAS
DRY at
time of
sampling,
check
here--
LABORATORY INFORMATION
Date sample analyzed:_ I I IL11 - 11` 111 ZD
Laboratory Name: ��c-,
�1 "�K ,
Certification No. (05
PARAMETERS NOTE: Values should reflect dissolved and colloidal concentrations.
COD mg/I
Nitrite (NO2) as N
mg/I
Pb - Lead mg/I
Coliform: MF Fecal 4', Cp k /100ml
Nitrate (NO3) as N 4 ,14D mg/I
Zn - Zinc mg/I
Coliform: MF Total /100ml
Phosphorus: Total as P mg/I
(Note: Use MPN method for highly turbid samples)
Orthophosphate
mg/I
Other (Specify Compounds and Concentration Units):
Dissolved Solids: Total W'B mg/I
Al - Aluminum
mg/I
pH (when analyzed) 5 ,(p units
Ba - Barium
mg/I
TOC < I , Q mg/I
Ca - Calcium
mg/I
Chloride oa * mg/I
Cd - Cadmium
mg/I
Arsenic mg/I
Chromium: Total
mg/I
Grease and Oils mg/I
Cu - Copper
mg/I
ORGANICS: (by GC, GC/MS, HPLC)
Phenol mg/I
Fe - Iron
mg/I
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate mg/I
Hg - Mercury
mg/I
Report Attached? X Yes (1) ❑ No (0)
Specific Conductance µMhos
K - Potassium
mg/I
VOC method #
Total Ammonia mg/I
Mg - Magnesium
mg/I
method #
(Ammonia Nitrogen, NH3as N, Ammonia Nitrogen, Total)
Mn -Manganese
mg/I
method #
TKN as N mg/I
Ni - Nickel
mg/I
method #
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs:
mg Effluent Total VOCs: mg/L VOC Removal%
Altr,coali�s b RC J '�g, y' a&)UjVk40 la 13
Permittee (or Authorized Agent) Name and Title - Please print or type Signature of Permittee (or Authorized Aqent) ;Date)
GW-59 Rev.1/2007

G, W-;')A Cc ►Nu>t,tt NNE, ttl?F�c�t� r t,-c>,tz,q
rsuG,,,ir r„u enc 1r ,t,;r.,itnrbrg p ai :n;fh GI 041p
Enter date monitoring results were due . ( � yyi11 this monitoring report (GW-59 and GW-594) gs
be submitted after the established due date?
Was any required information missing on the GW-59 report forms? --
_ YES
IF the answer to question t or 2 is "YE-,", :ist in the spec l.rovideu below the well identification number(s) and
explain the problems encountered in ohtainirtg the reollirod in'ormation.
3 \re any of the monitor wells in need of repair or maintenance (damaged casing, unlocked or missing cap, missing I l'IiS
identification plate, area overgrown, etc.)? ijthe answer is "Yrs", crtdnci the Regional f) f I _ rcc i�r�.,uidunce. i
jAre any monitored constituents equal to or above the estahiislied standards? -_--- I--
!r the answer b question 4 is `NO", skip tc section 8. -- -'-- - I S
If the answer to question 4 is "YES" list the affected wells individually with constituent(s) and concentrations) I —
exceeding standards in t;;e space provided below:
For the constituents identified in question 4 above, have standards b
same constituent(s) in the same well(s) in the last two years? een exceeded previously for the YES NO
If the answer to question 5 is "NO", skip to section 8. _
If the answer to question 5 is "YES'; list in the space provided below, each well with constituen(s) exceeding
standards, concentrations) reported, and sample collection date for each occurrence (for the last two years).
Are the monitoring wells listed in section 5 located at or beyond the review boundary?
YES NO
If the answer is "YES ", a groundwater quality problem may be occurring. CONTACT THE REGIONAL —
OFFICE IMMEDIATELY FOR GUIDANCE. If the answer is "NO", monitoring wells maybe improperly
located; contact the Regional Office.
Is the permittee implementing previously approved actions required by the Division in volving this YES I NO
groundwater quality problem?
_—�If the answer to question 7 is "YES", describe those actions in the space provided below.
If the answer to question 7 is "NO", contact the Regional Office within 90 days; an evacuation may be
required to determine the impact the waste disposal s stem is havin at the review and compliance
boundaries surroundin this facilct . Failure to do soma sub'ect the permittee to a Notice of Violation
fines, and/or penalties
8 The person completing this portion (GW-59A) of the monitoring report should sign below and submit this
form with G W-59 forms for required wells to the address provided at the top of the current G W-59 form.
I hereby a nowledge that the above information was evaluated and the information submitted in this
repo om Hance Report GW-59A) is true and complete to the best of my knowledge.
IR13lz-0
Signature of Permittee (or Authorized Agent)
Date
12i312003

ROUNDWATER QUALITY MONITORING:
OMPLIANCE REPORT FORM
AGILITY INFORMATION Please Print Clearly or Type
acility Name:
ermit Name (if different):
acility Address:
SUBMIT FORM ON YELLOW PAPER ONLY
NC �Xl t)(95 County
ntact Person. Y�>Qle maq-CL� Telephone#: q P- (rP 1- 106(o
:II Location/Site Name-TOWC) Ctq SkW0-M UJW"['P No. of wells to be sampled:
)EPARTMENT OF ENVIRONMENT 3 NATURAL RESOURCES
HVISION OF WATER QUALITY -INFORMATION PROCESSING UNIT
617 MAIL SERVICE CENTER, RALEIGH, NC 27699-1617 Phone: [phone]
P
NPDES
LL ID NUMBER (from Permit): rnW 44 y Date sample collected: 11 LA I e D
II Depth: ft. Well Diameter: a in.
Ith to Water Level: y ft. below measuring point Screened Interval: ft. to ft.
isuring Point is ft. above land surface Relative M.P. Elevation: ft.
Ime of water pumped/bailed before sampling: IS gallons
—--
tplesfor metals were ciilfected unfifte�ed: YES - - ❑ N'O and feld acidified:-- -[]YES---- - � NO
b
Expiration Date:
_ UIC
Other
'PE OF PERMITTED OPERATION BEING MONITORED
❑ Lagoon ❑ Remediation: Infiltration Gallery
Spray Field ❑ Remediation:
❑ Rotary Distributor ❑ Land Application of Sludge
❑ Water Source Heat Pump ❑ Other:
If WELL
FIELD ANALYSES: IWAS
pH (O.'JQunits Temp. J—to °C DRY at
Spec. Cond. % µMhos time of
sampling,
Odor e. check
Appearance c� mir— here:
:e sample analyzed: 7 - (� t ZO Laboratory Name: me- i'iecCertification No. k(PS
RAMETERS NOTE: alu s should reflect dissolved and colloidal concentrations.
COD mg/I Nitrite (NO2) as N mg/I Pb - Lead mg/I
Coliform: MF Fecal ash /100ml Nitrate (NO3) as N b,1CA mg/1 Zn - Zinc mg/1
Coliform: MF Total /100ml Phosphorus: Total as P n .pz(p mg/1
(Note: Use MPN method for highly turt)id samples) Orthophosphate mg/I Other (Specify Compounds and Concentration Units):
Dissolved Solids: Total
5S
mg/1
Al - Aluminum
mg/I
pH (when analyzed)
5J 11
units
Ba - Barium
mg/I
TOC
( • 0
mg/I
Ca - Calcium
mg/I
Chloride
3 '0
mg/1
Cd - Cadmium
mg/I
Arsenic
mg/I
Chromium: Total
mg/I
Grease and Oils
mg/I
Cu - Copper
mg/I
ORGANICS: (by GC, GC/MS, HPLC)
Phenol
mg/I
Fe - Iron
mg/I
(Specify test and method #. ATTACH LAB REPORT.)
Sulfate
mg/I
Hg - Mercury
mg/I
Report Attached? 14 Yes (1) ❑ No (0)
Specific Conductance
µMhos
K - Potassium
mg/I
VOC . method #
Total Ammonia < Dj mg/I Mg - Magnesium mg/l
(Ammonia Nitrogen, NH3 as N, Ammonia Nitrogen, Total)
Mn -Manganese mg/1
TKN as N mg/I Ni - Nickel mg/I
For Remediation Systems Only (Attach Lab Reports): Influent Total VOCs:
E)aie MOVhe_,�. s �)i2C
Permitlee (or Authorized Aqent) Name and Title - Please print or type
GW-59 Rev.112007
mg/L Effluent Total VOCs:
of Permittee (or Authorized Agent)
method #
method #
method #
mg/L VOC Removal%
wmcr

c.Av-59A COMPLIANCE, RV,1101t"r i>(•rmil tFW 0ti140LVo
SrrGrrlit nor eev..•b nrrritnrun' nr ni :1411 G ` } II( rll (r l6-ill it rr Nr�•,
J
j er date monitoring results were due . ( 'ST W
Entill this monitoring report (GW be submitted after the established due date
. —.7 —yt,ll cu 1111urmanon missing on the GW-59 report forms?
and GW-59A) I YES
It -trio answer to question t or 2 is "YE list bt the spec l•rovideu below the welt idertif,'ca.'ian numbers) and
explain the problems encountered in obtainiti the reomrod information.
3 Are any of the monitor wells in need of repair or maintenance (damaged casinke
g, unlocd or missing cap, missing I I
identification plate. area overgrown, etc.(
lfthe alutvvr is "Yes", cerr(nct the Regiunlo ke is — —�I 1'I.ti
rcc for uidunce. I
Are any monitored cone stitunts equal to or above the estahlished standards?
!r the answer to question 4 is 'NO", ski section 8. --- — P tc
If the answer to question 4 is "YES" list the affected wells individually with constituent(s) and concentration(s)
exceeding standards in tl,e space provided below:
j For the constituents identified in question 4 above, have standards been exceeded previously for the
same constituent(s) in the same well(s) In the last two years? YES NO
If the answer to question 5 is "NO" skip to section 8.
!f the answer to question 5 is "VESlist in the space provided below, each well with constituen(s) exceeding
standards, concentrations) reported, and sample collection date for each occurrence (for the last two years).
6
Are the monitoring wells listed in section 5 I
at or beyond the review boundary?
If the answer is "YES ", a groundwater quality problem may be occurring. CONTACT THE REGIONAL
OFFICE IMMEDIATELY FOR GUIDANCE. If the answer is "NO", monitoring wells may be improperly
located; contact the Regional Office.
Is the permittee implementing previously approved actions require
groundwater quality problem? d by the Division involving this
Ir rc drrswer to question 7 is "YES", describe those actions in the— a spacprovided below.
If the answer to question 7 is "NO", contact the Re ional Office within 90 days; an evaluation may be
required to determine the impact the waste disposal system is having at the review and com liance
boundaries surroundingthis facility. Failu to do so May subject the ermittee to a Notice of Violation
fines. and/or penalties
8 The person completing this portion (G W-59A) of the monitoring report should sign below and submit this
form with GW-59 forms for required wells to the address provided at the top of the current GW-59 form.
I hereby acknowledge that the above information was evaluated and the information submitted in this
repo pliance Report GW-59A) is true and complete to the best of my knowledge.
12
gnature of Permittee (or Authorized Agent) 1J I�
Date
YES I NO
YES I NO
GAV-59A 12/3/21103

Meritech, Inc.
Environmental Laboratory
Laboratory Certification No.165
Page 1
Contact: Janet Parrott
Report Date:
11/17/2020
Client: Town of Stovall
P.O. Box 100
Stovall, NC 27582
Date Sample Rcvd:
11/4/2020
Meritech Work Order #
11042053 Sample: MW #1 Grab
11/4/20
Parameters
Result Analysis Date
Reporting Limit
Method
Total Dissolved Solids
58 mg/L 11/5/20
10.0 mg/L
SM 2540C
Ammonia, Nitrogen
<0.1 mg/L 11/12/20
0.1 mg/L
EPA 350.1
Chloride
5.0 mg/L 11/9/20
0.50 mg/L
SM 4500 Cl B
Nitrate, Nitrogen
0.75 mg/L 11/5/20
0.10 mg/L
EPA 353.2
Phosphorus, total
<0.020 mg/L 11/11/20
0.020 mg/L
EPA 200.7
Fecal Coliform
<1 col/100 ml 11/4/20
1 col/100 ml
SM 9222 D
TOC
5.08 mg/L 11/6/20
1.0 mg/L
SM 5310C
pH
5.9 S.U. 11/5/20
1.0 -14.0 S.U.
SM 4500-HB
EPA 6200B
Attached 11/5/20
-
EPA 6200B
Meritech Work Order #
11042054 Sample: MW #2 Grab
11/4/20
Parameters
Result Analysis Date
importing Limit
Method
Total Dissolved Solids
79 mg/L
11/5/20
10.0 mg/L
SM 2540C
Ammonia, Nitrogen
<0.1 mg/L
11/12/20
0.1 mg/L
EPA 350.1
Chloride
12.5 mg/L
11/9/20
0.50 mg/L
SM 4500 CI B
Nitrate, Nitrogen
0.49 mg/L
11/5/20
0.10 mg/L
EPA 353.2
Phosphorus, total
0.046 mg/L
11/11/20
0.020 mg/L
EPA 200.7
Fecal Coliform
1 col/100 ml
11/4/20
1 col/100 ml
SM 9222 D
TOC
<1.0 mg/L
11/6/20
1.0 mg/L
SM 5310C
pH
6.0 S.U.
11/5/20
1.0 - 14.0 S.U.
SM 4500-HB
EPA 6200B
Attached
11/5/20
-
EPA 6200E
642 Tamco Road, Reidsville, North Carolina 27320
tel.[phone] fax.[phone]

Meritech, Inc.
Environmental Laboratory
�,,,� Laboratory Certification No.165
0971
Contact: Janet Parrott
Date:
Page 2Report
11/17/2020
Client: Town of Stovall
P.O. Box 100
Stovall, NC 27582
Date Sample Rcvd:
11/4/2020
Meritech Work Order #
11042055 Sample: MW #3 Grab
11/4/20
Parameters
Result
Analysis Date
Reporting Limit
Method
Total Dissolved Solids
63 mg/L
11/5/20
10.0 mg/L
SM 2540C
Ammonia, Nitrogen
<0.1 mg/L
11/12/20
0.1 mg/L
EPA 350.1
Chloride
2.5 mg/L
11/9/20
0.50 mg/L
SM 4500 Cl B
Nitrate, Nitrogen
<0.10 mg/L
11/5/20
0.10 mg/L
EPA 353.2
Phosphorus, total
0.043 mg/L
11/11/20
0.020 mg/L
EPA 200.7
Fecal Coliform
<1 col/100 ml
11/4/20
1 col/100 ml
SM 9222 D
TOC
<1.0 mg/L
11/6/20
1.0 mg/L
SM 5310C
PH
5.6 S.U.
11/5/20
1.0 - 14.0 S.U.
SM 4500-HB
EPA 6200B
Attached
11/5/20
-
EPA 6200B
Meritech Work Order #
11042056 Sample: MW #4 Grab
11/4/20
Parameters
Result
Analysis Date
Reporting Limit
Method
Total Dissolved Solids
58 mg/L
11/5/20
10.0 mg/L
SM 2540C
Ammonia, Nitrogen
<0.1 mg/L
11/12/20
0.1 mg/L
EPA 350.1
Chloride
3.0 mg/L
11/9/20
0.50 mg/L
SM 4500 Cl B
Nitrate, Nitrogen
0.19 mg/L
11/5/20
0.10 mg/L
EPA 353.2
Phosphorus, total
0.026 mg/L
11/11/20
0.020 mg/L
EPA 200.7
Fecal Coliform
25 col/100 ml
11/4/20
1 col/100 ml
SM 9222 D
TOC
<1.0 mg/L
11/6/20
1.0 mg/L
SM 5310C
pH
5.7 S.U.
11/5/20
1-14 SU
SM4500H+B
EPA 6200B
Attached
11/5/20
-
EPA 6200B
1 hereby certify that I have reviewed and approve these data.r L b rp C)f�'r )
Laboratory Representative
642 Tamco Road, Reidsville, North Carolina 27320
tel.[phone] fax.[phone]

MERITECH, INC.
Environmental Laboratories
Laboratory Certification #165
Client:
Town of Stovall Meritech ID#: 11042053
Project:
November Analysis: 11 /05/20
Client Sample ID:
MW #1 Analyst: VWV
Sample Collection:
11/04/20 Dilution Factor: 1
Report Date: 11/13/20
SM-6200B VOLATILE ORGANICS - Water
Acetone
< 50.0 ug/L
cis-1,3-Dichloropropene
< 0.500 ug/L
Benzene
< 0.500 ug/L
trans-1,3-Dichloropropene
< 0.500 ug/L
Bromobenzene
< 0.500 ug/L
Ethanol
< 50.0 ug/L
Bromodichloromethane
< 0.500 ug/L
Ethyl benzene
< 0.500 ug/L
Bromochloromethane
< 0.500 ug/L
2-Hexanone
< 1.00 ug/L
Bromoform
< 0.500 ug/L
Hexachlorobutadiene
< 0.500 ug/L
Bromomethane
< 0.500 ug/L
Isopropylbenzene
< 0.500 ug/L
2-Butanone (MEK)
< 5.00 ug/L
p-lsopropyltoluene
< 0.500 ug/L
n-Butylbenzene
< 0.500 ug/L
Methylene chloride
< 0.500 ug/L
sec-Butylbenzene
< 0.500 ug/L,
Methyl Isobutyl Ketone (MIBK)
< 0.500 ug/L
tert-Butylbenzene
< 0.500 ug/L
Naphthalene
< 0.500 ug/L
Carbon Tetrachloride
< 0.500 ug/L
n-Propylbenzene
< 0.500 ug/L
Chlorobenzene
< 0.500 ug/L
Styrene
< 0.500 ug/L
Chloroethane
< 0.500 ug/L
1, 1, 1,2-Tetrachloroethane
< 0.500 ug/L
Chloroform
< 0.500 ug/L
1,1,2,2-Tetrachloroethane
< 0.500 ug/L
Chloromethane
< 0.500 ug/L
Tetrachloroethee (PCE)
< 0.500 ug/L
2-Chlorotoluene
< 0.500 ug/L
Toluene
< 0.500 ug/L
4-Chlorotoluene
< 0.500 ug/L
1, 1, 1 -Trichloroethane
< 0.500 ug/L
Dibromochloromethane
< 0.500 ug/L
1,1,2-Trichloroethane
< 0.500 ug/L
1,2-Dibromo-3-chloropropane
< 0.500 ug/L
Trichloroethene (TCE)
< 0.500 ug/L
1,2-Dibromoethane(EDB)
<0.500 ug/L
1,2,3-Trichlorobenzene
<0.500 ug/L
Dibromomethane
< 0.500 ug/L
1,2,4-Trichlorobenzene
< 0.500 ug/L
Dichlorodifluoromethane
< 0.500 ug/L
1,2,3-Trichloropropane
< 0.500 ug/L
1, 1 -Dichloroethane
< 0.500 ug/L
Trichlorofluoromethane
< 0.500 ug/L
1,2-Dichloroethane
< 0.500 ug/L
1,2,4-Trimethylbenzene
< 0.500 ug/L
1,4-Dichlorobenzene
< 0.500 ug/L
1,3,5-Trimethylbenzene
< 0.500 ug/L
1,2-Dichlorobenzene
< 0.500 ug/L
Vinyl acetate
< 1.00 ug/L
1,3-Dichlorobenzene
< 0.500 ug/L
Vinyl chloride
< 0.500 ug/L
I,1-Dichloroethene
<0.500 ug/L
m/p-Xylenes
<1.00 ug/L
cis-1,2-Dichloroethene
<0.500 ug/L
o-Xylene
<0.500 ug/L
trans-1,2-Dichloroethene
<0.500 ug/L
1,2-Dichloropropane
< 0.500 ug/L
Additional Compounds
1,3-Dichloropropane
< 0.500 ug/L
Methyl-tert-butyl ether (MTBE)
< 0.500 ug/L
2,2-Dichloropropane
< 0.500 ug/L
Isopropyl ether (1PE)
< 0.500 ug/L
1, 1 -Dichloropropene
<0.500 ug/L
1,2-Dichloropropene
< 0.500 ug/L
I hereby certify that I have reviewed and approve these data.
Lab toryepr entative
642 Tamco Road * Reidsville, NC 27320
[phone] Ph * [phone] Fax

.,
MERITECH, INC.
Environmental Laboratories
Laboratory Certification #165
Client:
Town of Stovall Meritech ID#: 11042054
Project:
November Analysis: 1 I/05/20
Client Sample ID:
MW #2 Analyst: VWV
Sample Collection:
11/04/20 Dilution Factor: 1
Report Date: 11/13/20
SM-6200B VOLATILE ORGANICS -Water
Acetone
< 50.0 ug/L
cis-1,3-Dichloropropene
< 0.500 ug/L
Benzene
< 0.500 ug/L
trans-1,3-Dichloropropene
< 0.500 ug/L
Bromobenzene
< 0.500 ug/L
Ethanol
< 50.0 ug/L
Bromodichloromethane
< 0.500 ug/L
Ethyl benzene
< 0.500 ug/L
Bromochloromethane
< 0.500 ug/L
2-Hexanone
< 1.00 ug/L
Bromoform
< 0.500 ug/L
Hexachlorobutadiene
< 0.500 ug/L
Bromomethane
< 0.500 ug/L
Isopropylbenzene
< 0.500 ug/L
2-Butanone (MEK)
< 5.00 ug/L
p-Isopropyltoluene
< 0.500 ug/L
n-Butylbenzene
< 0.500 ug/L
Methylene chloride
< 0.500 ug/L
sec-Butylbenzene
< 0.500 ug/L
Methyl Isobutyl Ketone (MIBK)
< 0.500 ug/L
tert-Butylbenzene
< 0.500 ug/L
Naphthalene
< 0.500 ug/L
Carbon Tetrachloride
< 0.500 ug/L
n-Propylbenzene
< 0.500 ug/L
Chlorobenzene
< 0.500 ug/I,
Styrene
< 0.500 ug/L
Chloroethane
< 0.500 ug/L
1, 1, 1,2-Tetrachloroethane
< 0.500 ug/L
Chloroform
< 0.500 ug/L
1,1,2,2-Tetrachloroethane
< 0.500 ug/L
Chloromethane
< 0.500 ug/L
Tetrachloroethene (PCE)
< 0.500 ug/L
2-Chlorotoluene
< 0.500 ug/L
Toluene
< 0.500 ug/L
4-Chlorotoluene
<0.500 ug/L
1,1,1-Trichloroethane
<0.500 ug/L
Dibromochloromethane
< 0.500 ug/L
1,1,2-Trichloroethane
< 0.500 ug/L
1,2-Dibromo-3-chloropropane
< 0.500 ug/L
Trichloroethee (TCE)
< 0.500 ug/L
1,2-Dibromoethane (EDB)
< 0.500 ug/L
1,2,3-Trichlorobenzene
< 0.500 ug/L
Dibromomethane
< 0.500 ug/L
1,2,4-Trichlorobenzene
< 0.500 ug/L
Dichlorodifluoromethane
< 0.500 ug/L
1,2,3-Trichloropropane
< 0.500 ug/L
1, 1 -Dichloroethane
<0.500 ug/L
Trichlorofluoromethane
<0.500 ug/L
1,2-Dichloroethane
< 0.500 ug/L
1,2,4-Trimethylbenzene
< 0.500 ug/L
1,4-Dichlorobenzene
< 0.500 ug/L
1,3,5-Trimethylbenzene
< 0.500 ug/L
1,2-Dichlorobenzene
< 0.500 ug/L
Vinyl acetate
< 1.00 ug/L
1,3-Dichlorobenzene
< 0.500 ug/L
Vinyl chloride
< 0.500 ug/L
1, 1 -Dichloroethene
<0.500 ug/L
m/p-Xylenes
< 1.00 ug/L
cis-1,2-Dichloroethene
< 0.500 ug/L
o-Xylene
< 0.500 ug/L
trans-1,2-Dichloroethene
< 0.500 ug/L.
1,2-Dichloropropane
< 0.500 ug/L
Additional Compounds
1,3-Dichloropropane
< 0.500 ug/L
Methyl-tert-butyl ether (MTBE)
< 0.500 ug/L
2,2-Dichloropropane
< 0.500 ug/L
Isopropyl ether (IPE)
< 0.500 ug/L
1,1-Dichloropropene
<0.500 ug/L
1,2-Dichloropropene
<0.500 ug/L
1 hereby certify that I have reviewed and approve these data.
Lab toryre ntative
642 Tamco Road * Reidsville, NC 27320
[phone] Ph * [phone] Fax

MERITECH, INC.
Environmental Laboratories
Ad
�(
Laboratory Certification #165
Client:
Town of Stovall Meritech ID#: 11042055
Project:
November Analysis: 11/05/20
Client Sample ID:
MW #3 Analyst: VWV
Sample Collection:
11/04/20 Dilution Factor: 1
Report Date: 11/13/20
SM-6200B VOLATILE ORGANICS - Water
Acetone
< 50.0 ug/L
cis-1,3-Dichloropropene
< 0.500 ug/L
Benzene
< 0.500 ug/L
trans-1,3-Dichloropropene
< 0.500 ug/L
Bromobenzene
< 0.500 ug/L
Ethanol
< 50.0 ug/L
Bromodichloromethane
< 0.500 ug/L
Ethyl benzene
< 0.500 ug/L
Bromochloromethane
< 0.500 ug/L
2-Hexanone
< 1.00 ug/L
Bromoform
< 0.500 ug/L
Hexachlorobutadiene
< 0.500 ug/L
Bromomethane
< 0.500 ug/L
Isopropylbenzene
< 0.500 ug/L
2-Butanone (MEK)
< 5.00 ug/L
p4sopropyltoluene
< 0.500 ug/L.
n-Butylbenzene
< 0.500 ug/L
Methylene chloride
< 0.500 ug/L
sec-Butylbenzene
< 0.500 ug/L
Methyl Isobutyl Ketone (MIBK)
< 0.500 ug/L
tert-Butylbenzene
< 0.500 ug/L
Naphthalene
< 0.500 ug/L
Carbon Tetrachloride
< 0.500 ug/L
n-Propylbenzene
< 0.500 ug/L
Chlorobenzene
< 0.500 ug/L
Styrene
< 0.500 ug/L
Chloroethane
<0.500 ug/L
1, 1, 1,2-Tetrachloroethane
<0.500 ug/L
Chloroform
< 0.500 ug/L
1,1,2,2-Tetrachloroethane
< 0.500 ug/L
Chloromethane
< 0.500 ug/L
Tetrachloroethene (PCE)
< 0.500 ug/L
2-Chlorotoluene
< 0.500 ug/L
Toluene
< 0.500 ug/L
4-Chlorotoluene
< 0.500 ug/L
1, 1, 1 -Trichloroethane
< 0.500 ug/L
Dibromochloromethane
< 0.500 ug/L
1,1,2-Trichloroethane
< 0.500 ug/L
1,2-Dibromo-3-chloropropane
< 0.500 ug/L
Trichloroethee (TCE)
< 0.500 ug/L
1,2-Dibromoethane (EDB)
< 0.500 ug/L
1,2,3-Trichlorobenzene
< 0.500 ug/L
Dibromomethane
< 0.500 ug/L
1,2,4-Trichlorobenzene
< 0.500 ug/L
Dichlorodifluoromethane
< 0.500 ug/L
1,2,3-Trichloropropane
< 0.500 ug/L
1,1-Dichloroethane
< 0.500 ug/L
Trichlorofluoromethane
< 0.500 ug/L
1,2-Dichloroethane
< 0.500 ug/L
1,2,4-Trimethylbenzene
< 0.500 ug/L
1,4-Dichlorobenzene
< 0.500 ug/L
1,3,5-Trimethylbenzene
< 0.500 ug/L
1,2-Dichlorobenzene
< 0.500 ug/L
Vinyl acetate
< 1.00 ug/L
1,3-Dichlorobenzene
< 0.500 ug/L
Vinyl chloride
< 0.500 ug/L
1,1-Dichloroethene
< 0.500 ug/L
m/p-Xylenes
< 1.00 ug/L
cis-1,2-Dichloroethene
< 0.500 ug/L
o-Xylene
< 0.500 ug/L
trans-1,2-Dichloroethene
< 0.500 ug/L
1,2-Dichloropropane
<0.500 ug/L
Additional Compounds
1,3-Dichloropropane
< 0.500 ug/L
Methyl-tert-butyl ether (MTBE)
< 0.500 ug/L
2,2-Dichloropropane
< 0.500 ug/L
Isopropyl ether (IPE)
< 0.500 ug/L,
1, 1 -Dichloropropene
<0.500 ug/L
1,2-Dichloropropene
< 0.500 ug/L
I hereby certify that I have reviewed and approve these data.
Lab tory ative
642 Tamco Road * Reidsville, NC 27320
[phone] Ph * [phone] Fax

MERITECH, INC.
y
Environmental Laboratories
-
Laboratory Certification #165
Client:
Town of Stovall
Meritech ID#:
11042056
Project:
November
Analysis:
I 1 /05/20
Client Sample ID:
MW #4
Analyst:
VWV
Sample Collection:
11/04/20
Dilution Factor:
1
Report Date:
11/13/20
SM-6200B VOLATILE ORGANICS - Water
Acetone
< 50.0 ug/L
cis-1,3-Dichloropropene
< 0.500 ug/L
Benzene
< 0.500 ug/L
trans-1,3-Dichloropropene
< 0.500 ug/L
Bromobenzene
< 0.500 ug/L
Ethanol
< 50.0 ug/L
Bromodichloromethane
< 0.500 ug/L
Ethyl benzene
< 0.500 ug/L
Bromochloromethane
< 0.500 ug/L
2-Hexanone
< 1.00 ug/L
Bromoform
< 0.500 ug/L
Hexachlorobutadiene
< 0.500 ug/L
Bromomethane
< 0.500 ug/L
Isopropylbenzene
< 0.500 ug/L
2-Butanone (MEK)
< 5.00 ug/L
p-Isopropyltoluene
< 0.500 ug/L
n-Butylbenzene
< 0.500 ug/L
Methylene chloride
< 0.500 ug/L
sec -Butyl benzene
< 0.500 ug/L
Methyl lsobutyl Ketone (MIBK)
< 0.500 ug/L
tert-Butylbenzene
< 0.500 ug/L
Naphthalene
< 0.500 ug/L
Carbon Tetrachloride
< 0.500 ug/L
n-Propylbenzene
< 0.500 ug/L
Chlorobenzene
< 0.500 ug/L
Styrene
< 0.500 ug/L
Chloroethane
<0.500 ug/L
1, 1, 1,2-Tetrachloroethane
<0.500 ug/L
Chloroform
< 0.500 ug/L
1,1,2,2-Tetrachloroethane
< 0.500 ug/L
Chloromethane
< 0.500 ug/L
Tetrachloroethene (PCE)
< 0.500 ug/L
2-Chlorotoluene
< 0.500 ug/L
Toluene
< 0.500 ug/L
4-Chlorotoluene
<0.500 ug/L
1, 1, 1 -Trichloroethane
<0.500 ug/L
Dibromochloromethane
< 0.500 ug/L
1,1,2-Trichloroethane
< 0.500 ug/L
1,2-Dibromo-3-chloropropane
< 0.500 ug/L
Trichloroethene (TCE)
< 0.500 ug/L
1,2-Dibromoethane (EDB)
< 0.500 ug/L
1,2,3-Trichlorobenzene
< 0.500 ug/L
Dibromomethane
< 0.500 ug/L
1,2,4-Trichlorobenzene
< 0.500 ug/L
Dichlorodifluoromethane
< 0.500 ug/L
1,2,3-Trichloropropane
< 0.500 ug/L
],I-Dichloroethane
< 0.500 ug/L
Trichlorofluoromethane
< 0.500 ug/L
1,2-Dichloroethane
< 0.500 ug/L
1,2,4-Trimethylbenzene
< 0.500 ug/L
1,4-Dichlorobenzene
< 0.500 ug/L
1,3,5-Trimethylbenzene
< 0.500 ug/L
1,2-Dichlorobenzene
<0.500 ug/L
Vinyl acetate
< 1.00 ug/L
1,3-Dichlorobenzene
< 0.500 ug/L
Vinyl chloride
< 0.500 ug/L
1,1-Dichloroethene
<0.500 ug/L
m/p-Xylenes
< 1.00 ug/L
cis-1,2-Dichloroethene
< 0.500 ug/L
o-Xylene
< 0.500 ug/L
trans- l,2-Dichi oroethene
< 0.500 ug/L
1,2-Dichloropropane
< 0.500 ug/L
Additional Compounds
1,3-Dichloropropane
< 0.500 ug/L
Methyl-tert-butyl ether (MTBE)
< 0.500 ug/L
2,2-Dichloropropane
< 0.500 ug/L
Isopropyl ether (IPE)
< 0.500 ug/L
1, 1 -Dichloropropene
<0.500 ug/L
1,2-Dichloropropene
< 0.500 ug/L
I hereby certify that I have reviewed and approve these data.
Lab atory e ntative
642 Tamco Road * Reidsville, NC 27320
[phone] Ph * [phone] Fax

Chain of Custody Record COC
Client: Town OF Stovall
Address: PO Box 100
107 Main ST
Stoval,NC 27582
Attention: Janet Parrott
NPDES #:
Phone: [phone]
Fax:
Email:
Project: November
PO #:
MERITECH INC.
Environmental Laboratories
- A Division of Water Technology and Control, Inc.
642 Tamco Rd Phone [phone]
Reidsville, NC Fax: [phone]
27320 Email: wtclabObellsouth.net
Web Site: www.meritech-labs.com
Turn Around Time*
Sta (19 days)
`EX-::3
3 - 5 Day
0
24 - 48 Hr
0
Sample
Location/ID #
Sampling Dates & Times
`
Person Taking Sample (Signature): i �
Lab Use Only
START
END
Comp?
Grab?
#of
Cont..
Tests Required
j`� Clbn
i Ice?
pH OK?
C12 OK?
Date
Time
Date
Time
MW #1
L ,�G'
"fir
G
TDS,Chloride,TOC,NH3,NO3,Ptot,6200B
Fecal Coliform, pH=
MW#2
-L
G
TDS,Chloride,TOC,NH3,NO3,Ptot,6200B
t
1
Fecal Coliform, pH=
MW#3
-
G
TDS,Chloride,TOC,NH3,NO3,Ptot,6200B
Fecal Coliform, pH=
MW#4
G
'Y
TDS,Chloride,TOC,NH3,NO3,Ptot,6200B
S
t
Fecal Coliform, pH=
Method of Shipment:
Comments:
pH & TRC should be done on site
UPS
Fed Ex
Hand Delivery
[POtaher
L41'
Will these results be us d for regulatory purposes?
Yes No
* SH w rk must be ap roved prior to submitting samples.
Relinquished by:Q' Tyne
) ° / / u. D
Re ei d by: Dat : - �� O Time: /� J
✓/ LJ,
Ijell shed y: �! te: q ;\ I :
R celved by: Date: Time:
elinquishe by: Date: Time:
Re eI at 19 by: Date: Time:
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