WQ0039473_Monitoring - 11-2020_20210113

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Page
Permit No.: !11 •473
Facility Name: Atkinson Milling Company
County: Johnston,
R
Field
-®
Field Name:
• irrigation occur
Area (acres)::
Area (acres):
at this facility?
Cover Crop:
Cover Crop:'
Hourly =.
-.
, •
-.
Annual Rate (in):
Annual Kate (in):
Annual Rate (in):
Annual Rate (in):
Field Irrigated?
Field
Field Irrigated?
Monthly Loadi
12 Month Floating Total (in)7
i
i
%i

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1)
id the application rates exceed the limits in Attachment B of your permit? No
Page of
Were adequate measures taken to prevent effluent ponding in or runoff from the sites? Yes
Was a suitable vegetative cover maintained on all sites as specified in your permit? Yes
''lere all setbacks listed in your permit maintained for every application to each permitted site? Yes
"Jere all freeboards maintained in accordance with the specified freeboard heights in your permit? NIA
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
action(s) taken. Attach additional sheets if necessary.
Operator in Responsible Charge (ORC) Certification Permittee Certification I
CRC: Andrew Wheeler
,ertification No.: 1006226
grade: Phone Number: 919-631-7572
Has the OAC chaJt�ged �nce the previ�s NDAR-1? No
{ ,Z,L— T-))
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
Permittee:
Atkinson Milling Company
Signing Official: Andrew Wheeler
Signing Official's Title: Operations Manager
Phone Number: 919-631-7572 Permit Exp.: 4/30/23
la 3l-�
Signature Date
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 all qualified personnel properly gathered and evaluated 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

FORM: NDMR 03-12 NON -DISCHARGE MONITORING REPORT (NDMR) Page of
Permit No.: WQ0039473
T Facility Name: Atkinson Milling Company WWTF
County: Johnston
Month: l
Year: J G
PPI: 001
Flow Measuring Point:
Parameter Monitoring Point:
Parameter Code
50050-
00310
31616
00610
00625
00620
00600
00400
00665
00530
m
o
Q
U
O
_
£;
d in
U
O
3
LL
0
m
E
0
U
m
4)
LL
0
E
E
Q
0 0
Y�
0'z
c
F-
z
c
z
`°
°
F-
_
°
7
.'9 a
F°- o
a
m cII
r CL
U
24-hr
hrs
GPD
mg/L
#1100 mL
mg/L
mg/L
mg/L
mg/L
su
mg/L '
mg/L
1
2
3
4
d77
5
6
7
7DO
745`:
8
9
0o
'71Sa
i
38
U
10
11
12
13
14
15
16
17
18
19
0
20
21
22
23
24
25
700
11
t z
26
27
28
-7
c
29
30
31
Average:
Daily Maximum:
Daily Minimum:
Sampling Type:
Estimate
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Monthly Avg. Limit:
1,428
30
15
30

FORM: NDMR 03-12
NON -DISCHARGE MONITORING REPORT (NDMR)
Page of
Sampling Person(s)
Name: Andrew Wheeler
Name
Name: Microbac
Name:
Certified Laboratories
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit?
If the facility is non -compliant, please explain in the space below the reason(s) the facility was not in compliance. Provide in your explanation the date(s) of the non-compliance and describe the corrective
n +;nn to Lon Otf—h aririitinnal cheats if nPcessarv.
' d d— T S 5 C�''�-- fJlt►C � �� i�t �l. � GWl CB-h'��n � "�' '�tj (,,i a� t '[ 4 r G{ u.& UVt AYbA, %
jn' 17 r �-w�� � s«'�' ��er► off- � S� � ��zt.w Ord ary W l.a� 5�� Wf �0
'I 4v r�►r�- �,-I,.eS� ;twrw�� w ��-�'l cow-�p�f ��c. .
Operator in Responsible Charge (ORC) Certification
ORC: Andrew Wheeler
Certification No.: 1006226
Grade: Phone Number: 919-631-7572
Has the ORq changed since the previous NDMR? No
Signature Date
By this signature, I certify that this report is accurrate and complete to the best of my knowledge.
Permittee Certification
Permittee: Atkinson Milling Company
Signing Official: Andrew Wheeler
Signing Official's Title: Operations Manager
Phone Number: 919-631-7572 Permit Expiration: 4/30/2023
Signature Date
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 all qualified personnel properly gathered and evaluated 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.
Mail Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

L�7MICROBAC
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
KOL0332
Project Description
Wastewater Sample
For:
Mr. Andrew Wheeler
Atkinson Milling Company
95 Atkinson Mill Road
Selma, NC 27576
Administration
Brittany Smith
Monday, December 28, 2020
Please find enclosed the analytical results for the samples you submitted to Microbac Laboratories. Review and compilation of
your report was completed by Microbac Laboratories, Inc. - Fayetteville. If you have any questions, comments, or require further
assistance regarding this report, please contact your service representative listed above.
I certify that all test results meet all of the requirements of the accrediting authority listed within this report. Analytical results are
reported on a 'as received' basis unless specified otherwise. Analytical results for solids with units ending in (dry) are reported
on a dry weight basis. A statement of uncertainty for each analysis is available upon request. This laboratory report shall not be
reproduced, except in full, without the written approval of Microbac Laboratories. The reported results are related only to the
samples analyzed as received.
Microbac Laboratories, Inc.
2592 Hope Mills Rd 1 Fayetteville, NC 28306 1910.864.1920 p 1 www.microbac.com
Page 1 of 9

Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
KOL0332
Atkinson Milling Company Project Name: Wastewater Sample
Mr. Andrew Wheeler Project / PO Number: N/A
95 Atkinson Mill Road Received: 12/16/2020
Selma, NC 27576 Reported: 12/28/2020
Sample Summary Report
Sample Name
Spray Tank, Grab
Laboratory ID Client Matrix Sample Type Sample Begin Sample Taken Lab Received
KOL0332-01 Aqueous Grab 12/16/20 10:00 12/16/20 12:34
Page 2 of 9

�VMICROBAC`'
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
KOL0332
Analytical Testing Parameters
Client Sample ID: Spray Tank, Grab
Sample Matrix: Aqueous Collected By: Wheeler
Lab Sample ID: KOL0332-01 Collection Date: 12/16/2020 10:00
Microbiology
SM 9222 D-2006
Coliform, Fecal
Inorganics Total
Calculation
Total Nitrogen
EPA 300.0, Rv. 2.1 (1993)
Nitrate as N
Nitrite as N
EPA 351.2, Rv. 2 (1993)
Total Kjeldahl Nitrogen
SM 2540 D-2011
Total Suspended Solids
SM 4500-H+ B-2011
pH at 25 °C
SM 4500-NH3 G-2011
Ammonia as N
SM 4500-P F-2011
Phosphorus, Total
SM 5210 B-2011
BOD
Result RL
Units
DF Note
Prepared Analyzed
Analyst
190000 1.0
per 100ml-
1
12/16/20 1752 12/17/20 1611
MT
Result RL
Units
DF Note
Prepared Analyzed
Analyst
61.3 16.0
mg/L
16
12/18/20 1529
ZZZ
<0.250
0.250
mg/L
1
12/17/20 1343
12/17/20 1343
JDW
<0.250
0.250
mg/L
1
Al2
12/17/20 1343
12/17/20 1343
JDW
61.3
16.0
mg/L
16
12/18/20 1529
ZZZ
284
100
mg/L
40
12/22/20 1736
MT
6.8
1.0
S.U.
1
H
12/23/20 1005
TXN
21.7
5.00
mg/L
25
12/22/20 2115
12/22/20 2115
ZZZ
53
5.0
mg/L
25
12/21/20 1932
12/21/20 1932
ZZZ
> 2213.57
mg/L
1
G1, G5,
12/17/20 1313
12/22/20 1502
MT
G7
Microbac Laboratories, [tic.
2592 Hope Mills Rd I Fayetteville, NC 28306 1910.864.1920 p I www.microbac.com Page 3 of 9

(�)MICROBAC"
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
KOL0332
Batch Log Summary
EPA 300.0, Rv. 2.1 (1993) KLO1434 KOL0332-01 Spray Tank, Grab
KLO1434-DUP1 KOL0332-01
KLO1434-MS1 KOL0332-01
KLO1434-MS1 KOL0332-01
Method Batch Laboratory ID Client / Source ID
SM 9222 D-2006 KLO1438 KLO1438-BLK1
KLO1438-BLK2
KOL0332-01 Spray Tank, Grab
KLO1438-BS1
Method Batch Laboratory ID Client / Source ID
EPA 351.2, Rv. 2 (1993) KLO1806 KLO1806-MS1 KOL0218-01
KLO1806-MSD1 KOL0218-01
KLO1806-MS2 KOL0339-01
KLO1806-MSD2 KOL0339-01
KOL0332-01 Spray Tank, Grab
Method Batch LaboratoMLQ CIie,OL(, S9-Ucg 1D
SM 4500-P F-2011 KLO1818 KLO1818-MS1 KOL0199-01
KLO1818-MSD1
KOL0199-01
KLO1818-MS2
KOL0362-01
KLO1818-MSD2
KOL0362-01
KLO1818-MS3
KOL0383-01
KLO1818-MSD3
KOL0383-01
KOL0332-01
Spray Tank, Grab
Method hatch Laborat.ory ID Qlignt—-5-9.wc-Q-ID
SM 2540 D-2011 KLO1820 KOL0332-01 Spray Tank, Grab
KLO1820-BLK1
KLO1820-BLK2
KLO1820-D UP1 KOL0372-02
KLO1820-DUP2 KOL0371-01
KLO1820-BS1
Method_ Batch Laboratory ID Client I Source ID
SM 4500-NH3 G-2011 KLO1825 KLO1825-DUP1 KOL0382-01
KLO1825-MS1 KOL0382-01
KLO1825-DUP2 KOL0409-02
KLO1825-MS2 KOL0409-02
KOL0332-01 Spray Tank, Grab
Microbac Laboratories, Inc.
2592 Hope Mills Rd I Fayetteville, NC 28306 1910.864.1920 p I www.microbac.com Page 4 of 9

�MICROBAC`
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
KOL0332
Method
Batch Laboratory ID Client / Source ID
SM 4500-H+ B-2011
KL02302 KL02302-DUP2 KOL0430-01
KOL0332-01 Spray Tank, Grab
KL02302-DUP1 KOL0302-01
Method
Batch _�Q[ q1Y ID _ C ig q�argg ID
SM 5210 B-2011
KL02409 KOL0332-01 Spray Tank, Grab
KL02409-BLK1
KL02409-DUP1 KOL0366-01
KL02409-BS1
Batch Quality Control Summary: Microbac Laboratories, Inc. - Fayetteville
Spike Source %REC RPD
Microbiology Result RL Units Level Result %REC Limits RPD Limit Notes
Batch KLO1438 - Wet Chem Aqueous - SM 9222 D-2006
Blank (KLO1438-BLK1)
Coliform, Fecal <1.0 1.0
Blank(KLO1438-BLK2)
Coliform, Fecal <1.0 1.0
LCS (KLO1438-BS1)
Coliform, Fecal 3000 1.0
Inorganics Total Result RL
Batch KLO1434 -Wet Chem Aqueous - EPA 300.0, Rv. 2.1 (1993)
Duplicate (KLO1434-DUP1)
Nitrate as N
Nitrite as N
Matrix Spike (KLO1434-MS1)
Nitrate as N
Nitrite as N
Source: KOL0332-01
<0.250
0.250
<0.250
0.250
Source: KOL0332-01
10.8
0.250
12.0
0.250
Batch KLO1806 -Wet Chem Aqueous - EPA 351.2, Rv. 2 (1993)
Prepared: 12/16/2020 Analyzed: 12/17/2020
per
100ml-
Prepared: 12/16/2020 Analyzed: 12/17/2020
per
100ml-
Prepared: 12/16/2020 Analyzed: 12/17/2020
per 10 NR 0-200
100mL
Spike Source %REC RPD
Units Level Result %REC Limits RPD Limit Notes
Prepared & Analyzed: 12/17/2020
mg/L ND 10
mg/L ND 10
Prepared & Analyzed: 12/17/2020
mg/L 11.3 ND 96 90-110
mg/L 15.2 ND 79 90-110
Matrix Spike (KLO1806-MS1) Source: KOL0218-01 Prepared & Analyzed: 12/18/2020
Total Kjeldahl Nitrogen 4.92 1.00 mg/L ND 90-110
Matrix Spike (KLO1806-MS2) Source: KOL0339-01 Prepared & Analyzed: 12/18/2020
Total Kjeldahl Nitrogen 6.33 1.00 mg/L 0,984 90-110
Matrix Spike Dup (KLO1806-MSD1) Source: KOL0218-01 Prepared & Analyzed: 12/18/2020
Total Kjeldahl Nitrogen 4.93 1.00 mg/L ND 90-110 0.2 10
Matrix Spike Dup (KLO1806-MSD2) Source: KOL0339-01 Prepared & Analyzed: 12/18/2020
Total Kjeldahl Nitrogen 6.11 1.00 mg/L 0.984 90-110 4 10
Microbac Laboratories, Inc.
2592 Hope Mills Rd I Fayetteville, NC 28306 1910.864.1920 p j www.microbac.com Page 5 of 9

*MICROBAC
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
KOL0332
Inorganics Total Result RL
Batch KL01818 -Wet Chem Aqueous - SM 4500-P F-2011
Clarifier, GrabS (KLO1818-MS1)
Source: KOL0199-01
Phosphorus, Total
2.1
0.20
Outfall #1, GrabS (KLO1818-MS2)
Source: KOL0362-01
Phosphorus, Total
2.2
0.20
Clarifier, GrabS (KLO1818-MS3)
Source: KOL0383-01
Phosphorus, Total
2.1
0.20
Matrix Spike Dup (KLO1818-MSD1)
Source: KOL0199-01
Phosphorus, Total
2.0
0.20
Matrix Spike Dup (KLO1818-MSD2)
Source: KOL0362-01
Phosphorus, Total
2.3
0.20
Matrix Spike Dup (KLO1818-MSD3)
Source: KOL0383-01
Phosphorus, Total
2.2
0.20
Batch KLO1820 -Wet Chem Aqueous - SM 2540 D-2011
Spike Source
%REC
RPD
Units Level Result %REC
Limits
RPD
Limit Notes
Prepared & Analyzed: 12/21/2020
mg/L 2.0 0.088 100
90-110
Prepared & Analyzed: 12/21/2020
mg/L 2.0 0.16 102
90-110
Prepared & Analyzed: 12/21/2020
mg/L 2.0 0.097 99
90-110
Prepared &Analyzed: 12/21/2020
mg/L 2.0 0.088 98
90-110
2
200
Prepared & Analyzed: 12/21/2020
mg/L 2.0 0.16 105
90-110
3
200
Prepared & Analyzed: 12/21/2020
mg/L 2.0 0.097 104
90-110
5
200
PBWO1 (KLO1820-BLK1)
Prepared & Analyzed: 12/22/2020
Total Suspended Solids
<2.50
2.50
mg/L
PBW02 (KLO1820-BLK2)
Prepared &Analyzed: 12/22/2020
Total Suspended Solids
<2.50
2.50
mg/L
LCSWO1 (KLO1820-BS1)
Prepared & Analyzed: 12/22/2020
Total Suspended Solids
39.6
2.50
mg/L 39.2 101 95-105
Final Effluent, grabD (KLO1820-DUP1)
Source: KOL0372-02
Prepared &Analyzed: 12/22/2020
Total Suspended Solids
15.1
15.1
mg/L 15.7 4 10
DAF, CompositeD (KLO1820-DUP2)
Source: KOL0371-01
Prepared & Analyzed: 12/22/2020
Total Suspended Solids
50.0
41.7
mg/L 29.7 51 10
Batch KLO1825 - Wet Chem Aqueous
- SM 4500-NH3 G-2011
Effluent, compositeD (KLO1825-DUP1)
Source: KOL0382-01
Ammonia as N
<0.200
0.200
Effluent, compositeD (KLO1825-DUP2)
Source: KOL0409-02
Ammonia as N
0.212
0.200
Effluent, compositeS (KLO1825-MS1)
Source: KOL0382-01
Ammonia as N
1.04
0.200
Effluent, compositeS (KLO1825-MS2)
Source: KOL0409-02
Ammonia as N
1.19
0.200
Batch KL02302 -Wet Chem Aqueous - SM 4500-H+ B-2011
Prepared & Analyzed: 12/22/2020
mg/L 0.109
Prepared & Analyzed: 12/22/2020
mg/L 0.192
Prepared & Analyzed: 12/22/2020
mg/L 1.00 0.109 93 80-120
Prepared & Analyzed: 12/22/2020
mg/L 1.00 0.192 100 80-120
Outfall D, GrabD (KL02302-DUP1) Source: KOL0302-01 Prepared &Analyzed: 12/23/2020
pH at 25 °C 6.3 1.0 S.U. 6.3
OF #1, grabD (KL02302-DUP2) Source: KOL0430-01 Prepared & Analyzed: 12/23/2020
pH at 25 °C 6.3 1.0 S.U. 6.3
Microbac Laboratories, Inc.
2592 Hope Mills Rd I Fayetteville, NC 28306 1910.864.1920 p I www.microbac.com
10
10 10
0.8 10
0.3 10
Page 6 of 9

(�)MICROBAC`
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
KOL0332
Inorganics Total Result
Batch KL02409 -Wet Chem Aqueous - SM 5210 B-2011
Blank (KL02409-BLK1)
BOD
LCS (KL02409-BS1)
BOD
Duplicate (KL02409-DUP1)
BOD
<2.00
RL
2.00
163 2.00
Source: KOL0366-01
25.7 2.00
Spike Source %REC RPD
Units Level Result %REC Limits RPD Limit Notes
Prepared: 12/17/2020 Analyzed: 12/22/2020
mg/L
Prepared: 12/17/2020 Analyzed: 12/22/2020
mg/L .59596-115.4
Prepared: 12/17/2020 Analyzed: 12/22/2020
mg/L 41.9 48 30
Definitions
Al2: MS/MSD fail recovery, but the LCS passes criteria.
G1: The dissolved oxygen (DO) depletion of the dilution water blank exceeded 0.20 mg/L.
G5: The glucose/glutamic acid standard exceeded the range of 198 ± 30.5 mg/L.
G7: Less than 1 mg/L DO remained for all dilution sets. The reported value is an estimated greater than value and is
calculated from the dilution using the least amount of sample.
H: Analyte was prepared and/or analyzed outside of the analytical method holding time
mg/L: Milligrams per Liter
RL: Reporting Limit
RPD: Relative Percent Difference
S.U.: Standard Units
Cooler Receipt Log
Cooler ID: Default Cooler Temp: 2.6°C
Cooler Inspection Checklist
Ice Present or not required? Yes Shipping containers sealed or not required?
Yes
Custody seals intact or not required? Yes Chain of Custody (COC) Present?
Yes
COC includes customer information? Yes Relinquished and received signature on COC?
Yes
Sample collector identified on COC? Yes Sample type identified on COC?
Yes
Correct type of Containers Received Yes Correct number of containers listed on COC?
Yes
Containers Intact? Yes COC includes requested analyses?
Yes
Enough sample volume for indicated tests received? Yes Sample labels match COC (Name, Date & Time?)
Yes
Samples arrived within hold time? Yes Correct preservatives on COC or not required?
Yes
Chemical preservations checked or not required? Yes Preservation checks meet method requirements?
Yes
VOA vials have zero headspace, or not recd.? Yes
Project Requested Certification(s)
Microbac Laboratories, Inc. - Fayetteville
11 North Carolina DENR NPDES
Report Comments
Reviewed and Approved By:
Samples were received in proper condition and the reported results conform to 1
applicable accreditation standard unless otherwise noted.
The data and information on this, and other accompanying documents, represents only the
sample(s) analyzed. This report is incomplete unless all pages indicated in the footnote are Brittany Smith
present and an authorized signature is included. The services were provided under and Administration
subject to Microbac's standard terms and conditions which can be located and
reviewed at <httos://www.microbac.com/standard-terms-conditions>. Reported: 12/28/2020 12:44
Microbac Laboratories, Inc.
2592 Hope Mills Rd I Fayetteville, NC 28306 1910.864.1920 p I www.microbac.com Page 7 of 9

I00
`KOI'pL033 12*
Microbac-Fayetteville SHORT HOLQ5 ACCEP•E">=Q MONQmY - 7?'NdltfSQAc UNTIL a ODY RECOAd IN���I�I�I��IIII��II dIIII�III��
2592 Hope Mills Rd. Number u 111 IPII Ii
MICRO5AC Fayetteville, Nt m06 InstniCtlon5jj nback
TO BE COMli1.ETED BY MICROBA, G
invoice Address Turnaround Time days) on Receipt (2C) 2 e_ Therm ID
-- i) noutinearoun l� to / ousmess da 1 Temp. Up PL
Lab Report Address Client Name:
Client Named [ 3 RUSH• (notify lab) Holding Ylmhe � No N/A
Address: ------ '— Samples Received on 1 ?
Address: (needed by) s
City, State, Zip_ -----Report Type Custody $Adis Intact?e No NIA
City, State, ZiF B�11Nt0. t' Contact:
Contact: anw" 2 hze-1— Results Only I J Level 1 L 1 Level 2 L 1 LeV03 [ ] Level 4 [ ) EDO
Telephone No. % �" Telephone o.: Fax Ke-mail Ik
/•- G�t"c Send Invoice vi OMail (1 A ency/Program
Send Report 'via ]Mail [ r1 Fax r7l hCC� -- � No.: compliance Monitoring? Yes [ ] No [ 1 9
Project: Gldtilt. („)a,� J(1rt'"f Location:--.-
�/, :ampler Phone
e.@r�� sampler :.. .............[��-'-\.----'�-..__._....
Sampled by'(PR ._..•------•--^•--
s Matrix Types:SoiUSolid (S). Sludge. Oil. Wipe. Drinking Water (DW1. Groundwater (GW), Surface water ate,(Waste Water (WW).Other (specify)
.. Preservative TypeS:M HNO3. (2) H2SO4. (3) HCI, (4) NaOH, (5) Zinc Acetate, (6) Methanol. (7) Sodium Bisulfate, (R) Sodl°REQUESTED ANALYSIS (U) Unpre erved
Grab / / ! I Additional Notes
No. of reservative • i / I
4 (Date Time 11 °f type f 1
Container atrlk �t IJ I f
Lab ID Client Sample ID {Collected ollecte s i comp
I 1
Hazardous L1 Radioactive
Possible Hazard Identlfi( [ J Hazardous [ .
_ _..
Comments..
R l q ed By ksjge)�
nature)
Sam [1 Dispose a,4,appropri3te (l R hurn [ 1 Archive
"/lo-..A...L.:......:.......... • R-Z..._,.,,...
/Time - Received
Date/Time

*KOL0332" .
%�icrobac-Fayetteville
SHORT HOLDS ACCEPTED M+aa!'1DAY - THifRs''DAY UNTIL 1600
(YiiIC,-R0E;AC 2533 Hope ttii:s Rd.
CHAIN of cu$TODY RECORC
�1 Fayetteville, NC 28306
Number r!J
t J f+Rlyiyl
Instructions n, back Jj�+
Lab Report Address Invoice Address
Turnaround Time TO BE COMPETED BYMICROBAo---.._ _...., ....
Client Name: - Client Name: �+G-
L J rcoutane to to i nusmess aaysl Temp. Up n Receipt (sC) 2. G Therm ID
� }
Address: 1� f W Address:
[ 7 RUSH* (notify lab) Holding Time
�tt
City, State, Zip 2iN�Q IVL % Ci State, Zi
ty, p
(needed b Sam 1
y) p es Received on I a Ye No N/A
Contact:
Contact: �/` (Jel[•-
Report Type Custody Seals Intact? Ye No N/A
s-"
Telephone No. 919 3 f %7 ia— Telephone N}o.:
Results Only [ ] Level 1 ( ] Level 2 [ ) Levi 13 [ j Level 4 [ ] EDD
Send Report via[ ] Mail [ ] Fax e-mail ��°ir`rr =�a�� F�7]1eu .C�t
—1YL
Send Invoice vi [ J Mail [ ) Fax Ke-mail
Project: i;)46(t (r )Vk" &4�Location:
PO No.: Compliance Monitoring? Yes [ ) No [ ) Agency/Program
�r'
Sampled by (PRINT) j�'eyAlk / Lc 00t•F� — Sampler Signature:
» » _ ;ampler Phone No.: 10
Matrix Types:Soil/Solid (S), Sludge, Oil, Wipe, Drinking Water (DW). Groundwater
(GW), Surface Water (SW), Waste Water (WW). Other (specify)
** Preservative Types:(1) HNO3, (2) H2SO4, (3) HCI, (4) NaOH, (5) Zinc Acetate, (6) Methanol. (7) Sodium Bisulfate, (8) Sodium Thiosulfate, (9) Hexane, (U) UnpreServed
!Date jjj Time ) No. of �o� {Presery
Lab ID Client Sample ID j �, Containeat r rod;
i Collected Collette s I i
! i E Comp 1
Additional Notes
I
;
I
i
:
- -- - = -_.......
_...... _.._
..... }...........
}_._._»...... .� ».»..».».....»
»».».»»......._._.._._._.._....(......._.._._.._.._.._....._ ..... .......» .....
. .............. .. ....1................j....
•
.. _... .......... ..
_»..... .............. _................ _».__»..»...».
I
1
t?
I
1
Possible Hazard Identifi( [ ] Hazardous
Hazardous [ ] Radioactive
t-ed By n re)
' "i VLy I ,-
uished By(s nature)
Sam [ ] Dispose as. • ropriate [ ] Reyfurn [ ) Archive
id rs
DateM;ne 1 ived y ur) �- Ime�
Date/Time Received