WI0400575_Permit (Issuance)_20210823

NC Department of Environmental Quality — Division of Water Resources (DWR)
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small -Scale Injection Operations — Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells is located within an area that does not exceed five percent of the land surface
above the known extent of groundwater contamination. An individual permit shall be required to conduct more
than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells - Used to inject ambient air to enhance in -situ treatment of soil or groundwater.
5) In -Situ Thermal Wells (IST) — Used to `heat' contaminated groundwater to enhance remediation.
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: July 16 , 2021 PERMIT NO. W 10400575 (to be filled in by DWR)
NOTE- If this NOI is being submitted as notification of a modification of a previously issued NOI for this site (e.g.,
different injection wells, plume, additives, etc.) and still meets the deemed permitted by rule criteria, provide the
previously assigned permit tracking number and any needed relevant information to assess and approve injection:
A.
B.
Permit No. WI Issued Date:
WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well Complete sections B through F, J, M
(2) Aquifer Test Well . Complete sections B through F, J, M
(3) Passive Injection System Complete sections B through F, H-M
(4) X Small -Scale Injection Operation Complete sections B through M
(5) Pilot Test Complete sections B through M
(6) Tracer Injection Well Complete sections B through M
(7) In -Situ Thermal (IST) Well Complete sections B through M
STATUS OF WELL OWNER: Choose an item.
Deemed Permitted GW Remediation NOI Rev. 2-17-2020
Page 1

C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): L&L Food Stores / Dan Daly
Mailing Address: PO Box 699 — 706 E Church St.
City: Nashville State: NC Zip Code: 27856 County: Nash
Day Tele No.: 252-459-3146 Cell No.: 252-903-8432
EMAIL Address: [e-mail] Fax No.: 252-459-2675
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: L&L Roses, LLC / Trey Watkins
Company Name
Mailing Address: 613 US HWY 158 Bypass
City: Henderson State: NC Zip Code: 27537 County: Vance
Day Tele No.: 252-438-7141 Cell No.: 919-610-1033
EMAIL Address: [e-mail] Fax No.:
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Ryan Kerins
Company Name Terraquest Environmental Consultants, P.C.
Mailing Address: 100 East Ruffin Street
City: Mebane State: NC Zip Code: 27302 County: Alamance
Day Tele No.: 919-563-9091 Cell No.: 919-906-0960
EMAIL Address: [e-mail] Fax No.: 919-563-9095
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: L&L Food Store #6
1765 Red Oak Road
City: Nashville County: Nash Zip Code: 27856
(2) Geographic Coordinates: Latitude**: 35 ° 59 ' 33.36 " or °
Longitude**: -77 ° 56 ' 1.176 " or °.
Reference Datum: WG584 Accuracy: +/- 2cm
Method of Collection: Google
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: 11,000 square feet
Land surface area of inj. well network: 800 square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: 7 (must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 2

H. INJECTION ZONE MAPS — Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES AT THE SITE — Provide a brief narrative
regarding the cause of the contamination, and purpose, scope, goals of the proposed injection activity:
Small scale injection of 4,000 gallons (1 pound OBC per gallon) broken up as 500 gallons into each of 8 points.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: 8 Proposed Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 5, 10, 15, 20, 25
(3) For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as -built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
K. INJECTION SUMMARY
NOTE: Only injectants approved by the epidemiology section of the NC Division of Public Health, Department
of Health and Human Services can be injected. Approved injectants can be found online at
http: //deq.nc. gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-approved-injectants. All other substances must be reviewed by the DHHSprior to use.
Contact the UIC Program for more info if you wish to get approval for a different additive. However, please
note it may take 3 months or longer. If no injectants are to be used use N/A.
Injectant: Oxygen Biochem Total Amt. to be injected (gal)/event: 4,000 gallons
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 3

Injectant: Total Amt. to be injected (gap/event:
Total Amt to be injected (gal/event):
No. of separate injection events: Total Amt. to be injected (gal):
Source of Water (if applicable):
L. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter OM result from the injection activity.
VOC Monitoring will be regulated by NCDWM-UST. Semi-annual sampling of monitoring wells for 6200E
analysis is anticipated.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "I hereby certify, under penally of law, that I am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct; operate, maintain, repair, and if applicable, abandon the
r)rj'tion w anjf all related appurtenances in accordance with the 1 SA NCAC 02C 0200 Rules."
Signature of Abplieant
Print or Type Full Name and Title
Property Owner (if the property is not owned by the Well Owner/Applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(15A NCAC 02C .0200)."
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its coon on Iand shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement '
Ling)E1 tkaaser;
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send 1 (one) bard color copy of this NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR -- UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted OW Remediation NOI Rev. 2-17-2020 Page 4

002726
ESTIMATED
EXTENT OF 2L
STANDARD
VIOLATION
004147
6
•a r
1
Dar
II*
p�
hi mvl =
cwxxmv
s
5
N
t
„
v
_
WW1
MWZ_
MW3
!WWI_
MW6
MVO.__
MAT_
MW9
MW1a
MW11
14W 12
44W13
MW1 4
3J13j71
3,P1321
3113/11
3J13/21
3,P13/21
3f1 221
3J13/21
3,P13/21
3f13221
3J13j71
3,P13/21
3f13221
3/13/21
3 21
3J20
..0.330
0 3aa
r0 330
50.330
a 330
33411
0 -_423
0 .133
0 -Yy0
5E1
429
0 `10
1243
m
..0410
0110
148
.0 410
0110
1o�u
.0430
0110
.0410
162
444
: .0300
259
LAZE
.0 300
: 01a0
67.3
.0100
▪ 01a0
7.371
0 .i00
. 01a0
.0300
5-13
3.71
c 1.60
7.3170
5.9531
_40
140
773
160
724
14,1113
_40
t 1.60
150
56.9
93
.0140
370
9E.E
t0==0
:07
.0 10
0-=0
'0710
ESs
0-=0
.0 740
.0?40
.0 40
0710
350
■47
..07(0
c07a0
c0 T00
.0'(0
▪ 0 7a0
3E3
.0'(0
▪ 0 700
.0 700
119
. 0300
910
1216
..0 820
. 0110
515
..0320
7 42
7.1111
..0320
. 0320
<0320
1E2
9.67
..0360
356
355
.0360
-:.a350
164
.0360
0279
571
.0190
=0160
.0190
635
336
'.0530
154
692
Y0130
.0130
17_5
.0130
0320
15.5
.0530
:as10
.0530
.0330
0130
200
104
256
'100
100
65.E
300
100
SEE
100
1.00
1.00
217
253
690
33.3
15
< 0 69]
< 0 69)
33.6
.01.
▪ 171
'0190
▪ 069)
<0 69]
Y0 690
< 0593
215nntla rd 600 -400 300 20 70 400 400 70 6 70
GCL 3000 29)0)] 34.530 3 -.0 20600 7. ..0 2- .0 25..0 25..0 6A00 ] 00
LEGEND
MONITORING WELL
a SOLE -SOURCE SUPPLY WELL
0 Proposed injection point
UST LEGEND
Current:
TA1: 10,000-GAL GASOLINE
TA2: 6,000-GAL GASOLINE
TA3: 1 ,000-GAL KEROSENE
Removed:
T1: 8,000-GAL GASOLINE
T2: 8,000-GAL GASOLINE
T3: 4,000-GAL GASOLINE
GRAPHIC SCALE
0' 20' 40'
1" = 40'
80'
0
z
0
z
NASHVILLE
L&L FOOD STORES
FIGURE NO.
CO
2
CD
CC
CHECKED BY:
co
O
0
PROJECT NO:
0
J
H
DRAWN BY:

/.//// // ESTIMATED EXTENT OF,
/
,ESTIMATED EXTENT OF 2L
STANDARD VIOLATION
0'-10' BGL
Lean Clay (CL)
Mostly medium stiff reddish —orange —tan clay,
few to trace fine sand.
10' — 20' BGL
Sandy Lean Clay (CL)
Medium stiff, red to orange to tan to white mostly clay,
with some silt and some fine—grained sand. Some gravel
noted from 14-15' BGL in MW8,9,10,11.
20' — 30' BGL
Silt (ML)
Medium stiff to soft, red to white to tan, mostly silt
with some clay and trace sand.
Estimated extent of STG
MSCC violation
Elevations are referenced to an arbitrary datum plane of
100.00'.
A detailed discussion of site geology along with boring logs
ore included in the CSA Report.
This drawing is a fence diagram. The distances between wells
do not correlate with a straight line between the first and last
well of the cross section. Some features have been projected
onto the traces.
*Depth to water measurements were collected during sampling
on 7/17/19 and on 4/15/20 only for the wells sampled as
pre —approved by the NCLUST TF. A complete set of water
levels was not collected at one time. The difference in water
table elevations is shown here accordingly.
ESTIMATED EXTEN
OF STG MSCC
VIOLATION
HORIZONTAL: 1" = 30'
VERTICAL: 1" = 10'
ESTIMATED
EXTENT OF 2L
STANDARD
VIOLATION

LEGEND
MONITORING WELL
SOLE —SOURCE SUPPLY WELL
The groundwater elevations as
measured on 2/16/21 are listed
in feet.
The Type III monitoring well
MW1 2 was not used in the
construction of this map.
The interpreted groundwater flow
direction is indicated by the
arrows placed perpendicular to
the contour lines.
Samples collected on 2/16/21
were lost in transit to the lab in
Texas due to the winter weather
event of 2021. The wells were
resampled on 3/13/21.
MP
Well IUD
Groundwater
Elevation (ft_j
MW1
98.35
MW2
94.77
MW3
95.53
N1W4
96.45
MW5
99.27
MW6
97.09
MW7
96.37
MVTh
96.10
1N1W9
95.78
MW 10
94.63
MW11
96.45
MW12
95.82
MW 13
95.11
MW14
96.83
UST
Current:
TA1: 10,000
TA2: 6,000—
TA3: 1 ,000—
Removed:
T1 : 8,000—
T2: 8,000—
T3: 4,000—
LEGEND
—GAL GASOLINE
GAL GASOLINE
GAL KEROSENE
GAL GASOLINE
GAL GASOLINE
GAL GASOLINE
GRAPHIC SCALE
0' 20' 40'
1" = 40'
80'
CD
0
W
U
Q
CC
'OTENTIOMETRIC
0)
z
CD O H
QZ
O
L,J 0
O Y O
(3O
0O ow z
o�
0_ w
J CO J_
J � _
0)
z
z
NASH ILL , NC
L&L FOOD STORES
rr)
FIGURE NO.
N
0)
CO
CD
Ct
CHECKED BY:
0
J
H
DRAWN BY:
co
0
0
PROJECT NO:
0
II
0 U
z
w

25'
TYPICAL INJECTION POINT DETAIL
LAND SURFACE
GENERAL INFORMATION
Well Driller:
Terraquest Environmental Consultants,
Jonathan R. Grubbs #3001
TEMPORARY BORING FOR INJECTION POINT
BOTTOM
TM. RRACII
ENVIRONMENTAL CONSULTANTS, P.C.
P.C. —

_MATERIAL SAFETY DATA SHEET
Oxygen BioChem (OBC)®
M.SDS Ref. No.: 1,18.44-8
Date Approved: 04/30/2006
Revision No.: 2
This document has been prepared to meet the rerluimments of the U.S. OSHA Hazard Communication
Standard, 29 CFR 1910.1200; the Canada's Workplace Ha2ardous Materials Information System (WHMIS)
and, the EC Directive, 2001/58/EC.
1. PRODUCT AND COMPANY IDENTIFICATION
PRODUCT NAME:
C:FYIRAL USE:
MANUFACTURER
FMC CORPORATION
FMC Pcroxygcns
1735 Market Street
Philadelphia, PA 19103
[phone] (General Information)
Oxygen BioChem (OBC)S
For chemical oxidation and aerobic biorcrnediation, petroleum
hydrocarbon remediation, creosote rentndiation and partially
halogenated hydrocarbon mmediation.
EMERGENCY TELEPHONE NUMBERS
[phone] (Medical U.S. - C'ill Collect)
For leak, fire, spill, or accident cinnrgcncics, call:
(800) 4244300 (CHEMTREC - U.S.A. Sc Canada)
2. HAZARDS IDENTIFICATION
EMERGENCY OVERVIEW:
m Odorless ofltwhitcfine granular solid (cony bavcseparatarn or noticcahlc. ix o-toncappcaratucc).
a> Oxidizer
m Contact with combustibles may cause fin:.
m Decomposes in storage under conditions of moisture (water/water vapor) and/or excessive heal causing
release of oxides of sulfur and oxygen that supports combustion. Decomposition could form a high
temperature melt_ See Section 10("Stabilityand Reactivity").
Deluge container with water at safe distance or in protected area.
co May he severely irritating to the ayes.
POTENTIAL HEALTH EFFECTS: Airborne dust may be irritating to eyes, no. I
throat and skin upon contact. Exposum to high Icvels of dust may cause difficulty in breathing insem
persons. No significant long tcmu inhalation hazard; in-itation usually subsides alter exposure ceases.
Page 1 of 10

Oxygen BioChent (OBC)® (F18-44-8)
Date: 04/30/2006
3. COMPOSITION / INFORMATION ON INGREDIENTS
Chemical Name
CAS#
Wt. %
EC No.
EC Class
Proprietary Mixture
None
Not classified
4. FIRST AID MEASURES
EYES: Immediately flush with water for at least 15 minutes, lifting the upper and lower eyelids
intermittently. See a medical doctor or ophthalmologist immediately.
SKIN: Wash with plenty of soap and water. Get medical attention if irritation occurs and persists.
INGESTION: Rinse mouth with water. Dilute by giving 1 or 2 glasses of water. Do not induce
vomiting Never give anything by mouth to an unconscious person. See a medical doctor immediately.
INHALATION: Remove to fresh air. If breathing difficulty or discomfort occurs and persists, obtain
medical attention.
NOTES TO MEDICAL DOCTOR: Modest irritation is the only expected effect. No
serious consequences are expected, except perhaps in the case of direct eye contact. Contaminated external
surfaces should be flooded with water, and direct eye contact deserves ophthalmologic evaluation. If
ingested, gastrointestinal irritation but not caustic burns are to be expected; dilution with water indicated as
may be gastric evacuation via emesis or lavage if large doses or severe irritation is evident. Demulcents
should be helpful. No systemic effects are expected though human toxicity data is sparse.
5. FIRE FIGHTING MEASURES
EXTINGUISHING MEDIA: Deluge with plenty of water.
FIRE / EXPLOSION HAZARDS: Product is non-combustible. Under fire conditions, may
decompose and release oxygen gas, which may intensify fire. Presence of water accelerates decomposition.
Mixtures with polysulfide polymers may ignite,
FIRE FIGHTING PROCEDURES: Use flooding quantities of water. Use water spray to
keep fire exposed containets cool. Do not use carbon dioxide or other gas filled fire extinguishers; they
will have no effect on decomposition. Wear full protective clothing and self-contained breathing apparatus.
Page 2 of 10

Oxygen BioChem (OBC)® (F18-44-8) Date: 04/30/2006
FLAMMABLE LIMITS: Non-combustible
SENSITIVITY TO IMPACT: Oxidizable materials can be ignited by grinding and may
become explosive.
SENSITIVITY TO STATIC DISCIIARGE: Not available
6. ACCIDENTAL RELEASE MEASURES
RELEASE NOTES: Confine and collect spill, put into an approved DOT container (do not return
to original container) and isolate for disposal. Isolated material should be monitored for signs of
decomposition (fuming / smoking). If spilled material is wet, dissolve with large quantities of water and
dispose as a hazardous waste. Runoff to sewer may create fire or explosion hazard (do not flush powdered
material into sewer). Dispose of wastes according to the method outlined in Section 13, "Disposal
Considerations".
7. HANDLING AND STORAGE
HANDLING: Avoid contact by using personal protective equipment. Use respiratory protective
equipment when release of airborne dust is expected. If compounded with organics or combustible
materials be sure to exclude moisture. Use clean plastic or stainless steel scoops only.
STORAGE: Keep dry (reacts with moisture). Use first in, first out storage system. Store unopened in
a cool, clean, dry place away from point sources of heat (e.g. steam pipes, radiant heaters, hot air vents or
welding sparks). Keep container tightly closed when not in use. Avoid contamination of opened product.
Avoid contact with reducing agents. In case of fire or decmpositoin (fuming / smoking) deluge with plenty
of water to control decomposition. Fore storage, refer to NFPA Bulletin 430 on storage of liquid and solid
oxidizing materials.
COMMENTS: VENTILATION: Provide mechanical general and/or local exhaust ventilation to
prevent release of dust into work environment. Spills should be collected into suitable containers to prevent
dispersion into the air. If ventilation is inadequate or not available, use dust respirator and eye protection.
8. EXPOSURE CONTROLS / PERSONAL PROTECTION
EXPOSURE LIMITS
Chemical Name
ACGIH
OSHA
Supplier
Proprietary Ingredient
0.1 mg/m3 (TWA)
Page 3 of 10

Oxygen BioChem (OBC)® (F18-44-8) Date: 04/30/2006
10. STABILITY AND REACTIVITY
CONDITIONS TO AVOID: Heat (decomposes at 275°C), moisture, reducing
agents. Grinding with organics,
STABILITY: Stable (decomposition could occur when exposed
to heat or moisture)
POLYMERIZATION: Will not occur
INCOMPATIBLE MATERIALS• Grinding mixtures with organics (oxidizable
materials can be ignited by grinding and may
become explosive); heavy metals. Acids, alkalis,
halides (fluorides, chlorides, bromides and
iodides), combustible materials, most metals and
heavy metals, oxidizable materials, other oxidizers,
reducing agents, cleaners, and organic or carbon
containing compounds. Contact with incompatible
materials can result in a material decomposition or
other uncontrolled reactions.
HAZARDOUS DECOMPOSITION PRODUCTS: Oxygen that supports combustion and oxides of
sulfur, nitrogen, and calcium hydroxide.
COMMENTS. PRECAUTIONARY STATEMENT: Use of persulfates in chemical reactions
requires appropriate precautions and design considerations for pressure and thermal relief.
Decomposing persulfates will evolve large volumes of gas and/or vapor, can accelerate exponentially with
heat generation, and create significant and hazardous pressures if contained and not properly controlled or
mitigated.
Use with alcohols in the presence of water has been demonstrated to generate conditions that require
rigorous adherence to process safety methods and standards to prevent escalation to an uncontrolled
reaction.
11. TOXICOLOGICAL INFORMATION
EYE EFFECTS' No data available for the mixture.
Proprietary Component* Non -irritating (rabbit)
Proprietary Component Severely irritaitng (unwashed); Minimally irritating (washed)
SKIN EFFECTS: No data available for the mixture.
Expected to be non-irritating.(rabbit)
DERMAL LD50' No data available for the mixture.
Proprietary Components: > 10 g/kg (rat)
ORAL LD50' No data available for the mixture.
Proprietary Component: 895 mg/kg (rat)
Proprietary Component: 5 g/kg (rat)
Page 5 of 10

Oxygen BioChem (OBC)® (F18-44-8) Date: 04/30/2006
13. DISPOSAL CONSIDERATIONS
DISPOSAL METHOD: Dissolve in water to allow the release of oxygen and dispose via a
treatment system in accordance with governmental agencies regulations. Contact appropriate regulatory
agency prior to disposal.
14. TRANSPORT INFORMATION
U.S. DEPARTMENT OF TRANSPORTATION (DOT)
PROPER SHIPPING NAME:
Oxidizing solid, n.o.s. (sodium persulfate,
calcium peroxide)
PRIMARY HAZARD CLASS/DIVISION: 5.1 (Oxidizer)
UN/NA NUMBER: UN 1479
PACKING GROUP: II
LABEL(S): 5.1 (Oxidizer)
PLACARD(S): 5.1 (Oxidizer)
MARKING(S): Oxidizing solid, n.o.s. (sodium persulfate,
calcium peroxide), UNi479
ADDITIONAL INFORMATION: Hazardous Substance/RQ: Not applicable
49 STCC Number: 4918733
This material is shipped in 55 Ib.
polyethylene pail with vented screw -on lid
(approx 6.5 gallon)
INTERNATIONAL MARITIME DANGEROUS GOODS (IMDG)
PROPER SHIPPING NAME:
Oxidizing solid, n.o.s. (sodium persulfate,
calcium peroxide)
INTERNATIONAL CIVIL AVIATION ORGANIZATION (ICAO) /
INTERNATIONAL AIR TRANSPORT ASSOCIATION (IATA)
PROPER SHIPPING NAME:
ADDITIONAL INFORMATION:
Page 7 of 10
Oxidizing solid, n.o.s. (sodium persulfate,
calcium peroxide)
Combination packaging is recommended
for air transport.

Oxygen BioChem (OBC)® (F18-44-8) Date: 04/30/2006
OTHER INFORMATION:
Place spilled product in suitable container and wash residue with plenty of water.
See Section 6 (Accidental Release Measures) above for additional instructions.
15. REGULATORY INFORMATION
UNITED STATES
SARA TITLE III (SUPERFUND AMENDMENTS AND REAUTHORIZATION ACT)
SECTION 311 HAZARD CATEGORIES (40 CFR 370):
Fire Hazard, Inmtediate (Acute) Health Hazard
SECTION 312 THRESHOLD PLANNING QUANTITY (40 CFR 370):
The Threshold Planning Quantity (TPQ) for this product, if treated as a mixture, is 10,000 lbs;
however, this product contains the following ingredients with a TPQ of less than 10,000 lbs.:
None
SECTION 313 REPORTABLE INGREDIENTS (40 CFR 372):
Not listed
CERCLA (COMPREHENSIVE ENVIRONMENTAL RESPONSE COMPENSATION AND
LIABILITY ACT)
CERCLA DESIGNATION & REPORTABLE QUANTITIES (RQ) (40 CFR 302.4):
Proprietary component: Unlisted, RQ = 100 lbs., Ignitability
TSCA (TOXIC SUBSTANCE CONTROL ACT)
TSCA INVENTORY STATUS (40 CFR 710):
Listed (components)
RESOURCE CONSERVATION AND RECOVERY ACT (RCRA)
RCRA IDENTIFICATION OF HAZARDOUS WASTE (40 CFR 261):
Waste Number: D001
CANADA
WHMIS (WORKPLACE HAZARDOUS MATERIALS INFORMATION SYSTEM):
Chemical Name: Proprietary Component
Product Identification Number: 1505
Hazard Classification / Division: Class C (Oxidizer), Class D, Div. 2, Subdiv. B. (Toxic)
Ingredient Disclosure List: Listed
Chemical Name: Proprietary Component
Product Identification Number: 1457
Hazard Classification / Division: Class D, Div 2, Subdiv. B, Class C (Oxidizer)
Ingredient Disclosure List: Listed
Page 8 of 10

Oxygen BioChem (OBC)® (F18-44-8) Date: 04/30/2006
INTERNATIONAL LISTINGS
Proprietary Component
Australia (AICS): Listed
China: Listed
Japan (ENCS): (1)-1131
Korea: KE-12369
Philippines (PICCS): Listed
Proprietary Component
Australia (AICS): Listed
China: Listed
Japan (ENCS): (1)-181
Korea: KE-04518
Philippines (PICCS): Listed
Proprietary Component
Australia (AICS): Listed
China: Listed
Japan (ENCS): (1)-190
Korea: ICE-04597
Philippines (PICCS): Listed
HAZARD, RISK AND SAFETY PHRASE DESCRIPTIONS:
EC Symbols: (Not classified as hazardous)
EC Risk Phrases: (Not classified as hazardous)
EC Safety Phrases: (Not classified as hazardous)
16. OTHER INFORMATION
HMIS
Health
2
Flammability
0
Physical Hazard
1
Personal Protection (PPE)
J
Protection = J (Safety goggles, gloves, apron & combination dust & vapor respirator)
HMIS = Hazardous Materials Identification System
Degree of Hazard Code:
4 = Severe
3 = Serious
Page 9 of 10

Oxygen BioChem (OBC)® (F18-44-8) Date: 04/30/2006
2 = Moderate
1 = Slight
0 = Minimal
NFPA
Health
2
Flammability
0
Reactivity
1
Special
OX
SPECIAL = OX (Oxidizer)
NFPA = National Fire Protection Association
Degree of Hazard Code:
4 = Extreme
3 = High
2 = Moderate
1 = Slight
0 = Insignificant
REVISION SUMMARY:
This MSDS replaces Revision #I, dated December 12, 2005.
Changes in information are as follows:
Section 1 (Product and Company Identification)
Section 16 (Other Information)
FMC Logo - FMC Corporation Trademark
Oxygen BioChem (OBC) - Trademark of Redox Tech, LLC
© 2006 FMC Corporation. All Rights Reserved.
FMC Corporation believes that the information and recommendations contained herein (including data and
statements) are accurate as of the date hereof. NO WARRANTY OF FITNESS FOR ANY PARTICULAR
PURPOSE, WARRANTY OF MERCHANTABILITY, OR ANY OTHER WARRANTY, EXPRESSED
OR IMPLIFD, IS MADE CONCERNING THE INFORMATION PROVIDED HEREIN. The information
provided herein relates only to the specific product designated and may not be applicable where such
product is used in combination with any other materials or in any process. It is a violation of Federal law to
use this product in a manner inconsistent with its labeling. Further, since the conditions and methods of use
are beyond the control of FMC Corporation, FMC Corporation expressly disclaims any and all liability as
to any results obtained or arising from any use of the product or reliance on such information.
Page 10 of 10