NC0001899_Response to NOVI-2021-LV-0820_20211111

Eco TIP West LLC
PO Drawer 9
Sanford, NC 27331
November 11, 2021
Vanessa E. Manual, Assistant Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
RE: Notice of Violation and Intent to Access Civil
Tracking Number: NOV-2021-LV-0820
Permit No. NC0001899
Moncure Holdings West WWTP
Chatham County
Dear Ms. Manual,
NC Dept ofEnvironmental Quality
NOV 15 2021
Penalty Raleigh Regional Office
Please except this letter as response to the Notice of Violation and Intent to Access Civil Penalty
issued to Moncure Holdings WWTP (Permit No. NC0001899) on November 1, 2021. This
violation occurred during the transition period between Withers Ravenel and Greener EHS
Solutions, LLC. The sample was collected by the Withers Ravenel personnel and observed by
the new operators taking over for Greener EHS Solutions, LLC. Nothing unusual was noted
during the sampling event.
We were notified on October 11, 2021, by the current operator that there were issues with the lab
data from 9/15/21 and 9/22/21 and they were being investigated. The data received from 9/15/21
was missing the Oil and Grease results and the 9/22/21 data indicated a high BOD, above the
permitted limit. Upon investigation, it was noted and communicated to us that the Oil and Grease
results were inadvertently left off of the report and a new revised report was issued. The operator
asked the Laboratory to analyze the COD for the 9/22/21 sample and the result was 38.8 mg/1.
The operator began running in house COD for process control and got similar results. The
certified lab report was update with the COD results and they were added to the September
eDMR. The certified lab also reran the BOD out of holding time and got a result of 14.98 mg/1.
Upon further investigation, the operator was told that the certified laboratory uses sodium
thiosulfate to neutralize chlorine in their BOD samples. The operator communicated to the lab
that no chlorine is added at the Moncure Holdings West WWTP and therefore sodium thiosulfate
should not be used since it can affect the BOD results.
As an extra precaution, the operator thoroughly cleaned all sampling equipment and ran COD in
house for all other samples collected. It should be noted that the in-house COD analysis has

indicated COD's ranging from 35-61 mg/1 over the last several weeks and all subsequent BOD
results have been non -detect. It should also be noted that no process wastewater and a very
miniscule amount of sanitary is being treated at this site. It is mainly stormwater collected in the
treatment ponds during rain events.
Attached to this letter is the revised report including the COD results and the raw data sent over
by the certified laboratory for the 9/22/21 BOD. If you have any further questions or concerns,
please contact Amanda Grenier at 919-356-6509.
Sincerely,
Kirk J. Bradley
Manager, Eco TIP West LLC
Attachment: Pace Analytical Revised report for 9/22/21
Pace Analytical Raw Data for 9/22/21 BOD
CC: Cheng Zhang, NC DEQ, Division of Water Resources, Raleigh Regional Office
Amanda Grenier, Greener EHS Solutions, LLC
WQS, Raleigh Regional Office — Enforcement File
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October 18, 2021
Amanda D. Grenier
Greener EHS Solutions
21 Selby Ct.
Holly Springs, NC 27540
RE: Project: Weekly Effluent -Revised Report
Pace Project No.: 92562697
Dear Amanda Grenier:
Pace Analytical Services, LLC
9800 Kincey Ave Suite 100
Huntersville NC 28078
[phone]
Enclosed are the analytical results for sample(s) received by the laboratory on September 22, 2021. The results relate only
to the samples included in this report. Results reported herein conform to the applicable TNI/NELAC Standards and the
laboratory's Quality Manual, where applicable, unless otherwise noted in the body of the report.
The test results provided in this final report were generated by each of the following laboratories within the Pace Network:
• Pace National - Mt. Juliet
• Pace Analytical Services - Asheville
• Pace Analytical Services - Eden
This revision was issued on 10/18/21 to report COD results, per client request.
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
Matthew Brainard
[e-mail]
[phone]
Project Manager
Enclosures
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CERTIFICATIONS
Project: Weekly Effluent -Revised Report
Pace Project No 92562697
Pace Analytical Services, LLC
9800 KinceyAve Suite 100
Huntersville. NC 28078
[phone]
Pace Analytical Services National
12065 Lebanon Road, Mt. Juliet, TN 37122
Alabama Certification #: 40660
Alaska Certification 17-026
Arizona Certification #: AZ0612
Arkansas Certification #: 88-0469
California Certification #: 2932
Canada Certification #: 1461.01
Colorado Certification #: TN00003
Connecticut Certification #: PH-0197
DOD Certification: #1461.01
EPA# TN00003
Florida Certification #: E87487
Georgia DW Certification #: 923
Georgia Certification: NELAP
Idaho Certification #: TN00003
Illinois Certification #: 200008
Indiana Certification #: C-TN-01
Iowa Certification #: 364
Kansas Certification #: E-10277
Kentucky UST Certification #: 16
Kentucky Certification #: 90010
Louisiana Certification #: A130792
Louisiana DW Certification #: LA180010
Maine Certification #: TN0002
Maryland Certification #: 324
Massachusetts Certification #: M-TN003
Michigan Certification #: 9958
Minnesota Certification #: 047-999-395
Mississippi Certification #: TN00003
Missouri Certification #: 340
Montana Certification #: CERT0086
Nebraska Certification #: NE-OS-15-05
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
North Carolina Drinking Water Certification #: 37712
Pace Analytical Services Eden
205 East Meadow Road Suite A, Eden. NC 27288
North Carolina Drinking Water Certification # 37738
Nevada Certification #: TN-03-2002-34
New Hampshire Certification #: 2975
New Jersey Certification #: TN002
New Mexico DW Certification
New York Certification # 11742
North Carolina Aquatic Toxicity Certification #: 41
North Carolina Drinking Water Certification # 21704
North Carolina Environmental Certificate # 375
North Dakota Certification #: R-140
Ohio VAP Certification # CL0069
Oklahoma Certification #: 9915
Oregon Certification #: TN200002
Pennsylvania Certification #: 68-02979
Rhode Island Certification #: LA000356
South Carolina Certification #: 84004
South Dakota Certification
Tennessee DWfChem/Micro Certification # 2006
Texas Certification #: T 104704245-17-14
Texas Mold Certification #: LAB0152
USDA Soil Permit #: P330-15-00234
Utah Certification #. TN00003
Virginia Certification #. VT2006
Vermont Dept. of Health ID# VT-2006
Virginia Certification # 460132
Washington Certification #. C847
West Virginia Certification #: 233
Wisconsin Certification #: 998093910
Wyoming UST Certification #: via A2LA 2926.01
A2LA-ISO 17025 Certification* 1461.01
A2LA•ISO 17025 Certification* 1461.02
AIHA-LAP/LLC EMLAP Certification #:100789
North Carolina Wastewater Certification #: 40
South Carolina Certification #: 99030001
VirginiaNELAP Certification #: 460222
North Carolina Wastewater Certification #: 633
VirginiaNELAP Certification #: 460025
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SAMPLE SUMMARY
Project: Weekly Effluent -Revised Report
Pace Project No.: 92562697
Pace Analytical Services, LLC
9800 Kincey Ave Suite 100
Huntersville, NC 28078
[phone]
Lab ID Sample ID Matrix Date Collected Date Received
92562697001 Effluent Comp Water 09/22/21 09:01 09/22/21 11:25
92562697002 Effluent Grab Water 09/22/21 09:01 09/22/21 11:25
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SAMPLE ANALYTE COUNT
Project: Weekly Effluent -Revised Report
Pace Project No 92562697
Pace Analytical Services, LLC
9800 Kincey Ave Suite 100
Huntersville. NC 28078
[phone]
Lab ID Sample ID
Method
Analytes
Analysts Reported Laboratory
92562697001 Effluent Comp
92562697002 Effluent Grab
PAN = Pace National - Mt. Juliet
PASI-A = Pace Analytical Services - Asheville
PASI-E = Pace Analytical Services - Eden
SM 2540D-2011 AED 1 PASI-E
SM 5210B-2011 SRS 1 PASI-E
SM 2540B-2011 ZMC 1 PASI-A
EPA 350.1 Rev 2.0 1993 NGP 1 PASI-A
SM 5220D-2011 JP1 1 PASI-A
EPA 1664E WAW 1 PAN
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ANALYTICAL RESULTS
Project: Weekly Effluent -Revised Report
Pace Project No.: 92562697
Pace Analytical Services, LLC
9800 Kincey Ave Suite 100
Huntersville, NC 28078
[phone]
Sample: Effluent Comp Lab ID: 92562697001 Collected: 09/22/21 09 01 Received: 09/22/21 11:25 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
2540D Total Suspended Solids Analytical Method: SM 2540D-2011
Pace Analytical Services - Eden
Total Suspended Solids 5.2 mg/L 2.8 1 09/24/21 13:28
5210E BOD, 5 day EDN Analytical Method: SM 5210B-2011 Preparation Method: SM 5210B-2011
Pace Analytical Services - Eden
BOD, 5 day 32.5 mg/L 2.0 1 09/23/21 20:59 09/28/21 17:21
2540B Total Solids Analytical Method: SM 2540B-2011
Pace Analytical Services - Asheville
Total Solids 101 mg/L 25.0 1 09/28/21 17:39
350.1 Ammonia Analytical Method: EPA 350.1 Rev 2.0 1993
Pace Analytical Services - Asheville
Nitrogen, Ammonia <0.10 mg/L 0.10 1 10/05/21 12:59 7664-41-7
5220D COD
Chemical Oxygen Demand
Analytical Method: SM 5220D-2011 Preparation Method: SM 5220D-2011
Pace Analytical Services -Asheville
38.8 mg/L
25.0 1 10/14/21 02:12 10/14/21 06:03
Sample: Effluent Grab Lab ID: 92562697002 Collected: 09/22/21 09:01 Received: 09/22/21 11:25 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No Qual
Wet Chemistry 1664E Analytical Method: EPA 1664E Preparation Method: 1664E
Pace National - Mt. Juliet
Oil and Grease
Date: 10/18/2021 11:58 AM
<5560 ug/L 5560 1 09/29/21 17:41 09/30/21 00:47 ML
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oo1JJO tetmOa2i OppIf
NC Dept of Environmental Quality

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QUALITY CONTROL DATA
Project: Weekly Effluent -Revised Report
Pace Project No.: 92562697
Pace Analytical Services, LLC
9800 KlnceyAve Suite 100
Huntersville. NC 28078
[phone]
QC Batch: 649236 Analysis Method: SM 2540D-2011
QC Batch Method: SM 2540D-2011 Analysis Description: 2540D Total Suspended Solids
Laboratory: Pace Analytical Services - Eden
Associated Lab Samples 92562697001
METHOD BLANK. 3405268 Matrix: Water
Associated Lab Samples. 92562697001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Suspended Solids mg/L <2.5 2.5 09/24/21 13:26
LABORATORY CONTROL SAMPLE: 3405269
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Total Suspended Solids mg/L 250 232 93 90-110
SAMPLE DUPLICATE 3405270
92562687001 Dup Max
Parameter Units Result Result RPD RPD Qualifiers
Total Suspended Solids mg/L 94.7 103 9 25
SAMPLE DUPLICATE: 3405271
92562744001 Dup Max
Parameter Units Result Result RPD RPD Qualifiers
Total Suspended Solids mg/L 84.8 42.1 67 25 D6
Results presented on this page are in the units indicated by the "Units" column except where an altemate unit Is presented to the right of the result.
Date: 10/18/2021 11 58AM
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QUALITY CONTROL DATA
Project: Weekly Effluent -Revised Report
Pace Project No.: 92562697
Pace Analytical Services, LLC
9800 KinceyAve. Suite 100
Huntersville, NC 28078
[phone]
QC Batch: 649085 Analysis Method: SM 5210B-2011
QC Batch Method: SM 5210B-2011 Analysis Description: 5210B BOD, 5 day Final EDN
Laboratory: Pace Analytical Services - Eden
Associated Lab Samples: 92562697001
METHOD BLANK: 3404670 Matrix: Water
Associated Lab Samples: 92562697001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
BOD, 5 day mg/L <2.0 2.0 09/28/21 16:37
LABORATORY CONTROL SAMPLE: 3404671
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
BOD, 5 day
mg/L 198 177 89 84.6-115.4
SAMPLE DUPLICATE: 3404673
92562756001 Dup
Parameter Units Result Result
RPD
Max
RPD Qualifiers
BOD, 5 day mg/L 64.2 60.8 6 25
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.
Date: 10/18/2021 11:58 AM
REPORT OF LABORATORY ANALYSIS
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QUALITY CONTROL DATA
Project: Weekly Effluent -Revised Report
Pace Project No 92562697
Pace Analytical Services, LLC
9800 Kincey Ave Suite 100
Hunterswlle. NC 28078
{704)875-9092
QC Batch' 1748696 Analysis Method: EPA 1664B
QC Batch Method: 1664E Analysis Description: Wet Chemistry 1664B
Laboratory: Pace National - Mt. Juliet
Associated Lab Samples: 92562697002
METHOD BLANK: R3710518-1 Matrix: Water
Associated Lab Samples: 92562697002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Oil and Grease ug/L <5000 5000 09/30/21 00:47
LABORATORY CONTROL SAMPLE & LCSD: R3710518-2 R3710518-3
Spike LCS LCSD LCS LCSD % Rec Max
Parameter Units Conc. Result Result % Rec % Rec Limits RPD RPD Qualifiers
OII and Grease
ug/L 40000 35300 35000 88.3 87.5 78.0-114 0.853 20
MATRIX SPIKE SAMPLE: R3710518-4
92562697002 Spike MS MS % Rec
Parameter Units Result Conc. Result % Rec Limits Qualifiers
Oil and Grease ug/L 2110 40000 32400 75.7 78.0-114 ML
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.
Date: 10/18/2021 11 58AM
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QUALITY CONTROL DATA
Project: Weekly Effluent -Revised Report
Pace Project No.: 92562697
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
QC Batch. 649728
QC Batch Method: SM 2540B-2011
Associated Lab Samples: 92562697001
Analysis Method: SM 2540B-2011
Analysis Description. 2540E Total Solids
Laboratory: Pace Analytical Services - Asheville
METHOD BLANK: 3407462 Matrix. Water
Associated Lab Samples: 92562697001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Solids mg/L <25.0 25.0 09/28/21 17:39
LABORATORY CONTROL SAMPLE: 3407463
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Total Solids mg/L 501 484 97 90-110
SAMPLE DUPLICATE: 3407464
92562697001 Dup
Parameter Units Result Result
RPD
Max
RPD Qualifiers
Total Solids mg/L 101 100 1 25
po ° puopoa ggtaiva
Results presented on this page are in the units Indicated by the "Units" column except where an altemate unit Is presented to the right of the result.
Date 10/18/2021 11 58 AM
REPORT OF LABORATORY ANALYSIS
NC Dept of Environmental Quality
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QUALITY CONTROL DATA
Project: Weekly Effluent -Revised Report
Pace Project No : 92562697
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
QC Batch: 650801 Analysis Method: EPA 350.1 Rev 2.0 1993
QC Batch Method: EPA 350 1 Rev 2.0 1993 Analysis Description 350-1 Ammonia
Laboratory: Pace Analytical Services - Asheville
Associated Lab Samples 92562697001
METHOD BLANK 3412913 Matrix: Water
Associated Lab Samples 92562697001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Nitrogen, Ammonia mg/L <0.10 0.10 10/05/21 12:49
LABORATORY CONTROL SAMPLE: 3412914
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Nitrogen, Ammonia mg/L 5 4 9 99 90-110
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 3412915 3412916
MS MSD
92562687002 Spike Spike MS MSD MS MSD % Rec Max
Parameter Units Result Conc. Conc. Result Result % Rec % Rec Limits RPD RPD Qual
Nitrogen, Ammonia mg/L ND 5 5 5.2 5.2 104 104 90-110 0 10
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 3412917 3412918
MS MSD
92562697001 Spike Spike MS MSD MS MSD % Rec Max
Parameter Units Result Conc. Conc. Result Result % Rec % Rec Limits RPD RPD Qual
Nitrogen, Ammonia
mg/L <0.10 5 5 5.1 5.1 102 101 90-110 1 10
Results presented on this page are in the units indicated by the "Units" column except where an altemate unit is presented to the right of the result.
Date 10/18/2021 11.58 AM
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QUALITY CONTROL DATA
Project Weekly Effluent -Revised Report
Pace Project No 92562697
Pace Analytical Services, LLC
9800 Kincey Ave Suite 100
Huntersville NC 28078
[phone]
QC Batch. 652495
QC Batch Method SM 5220D-2011
Associated Lab Samples. 92562697001
Analysis Method. SM 5220D-2011
Analysis Description: 5220D COD
Laboratory Pace Analytical Services • Asheville
METHOD BLANK: 3421373 Matrix: Water
Associated Lab Samples. 92562697001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Chemical Oxygen Demand mg/L <25 0 25 0 10/14/21 06.02
LABORATORY CONTROL SAMPLE: 3421374
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: 3421375 3421376
MS MSD
92562697001 Spike Spike MS MSD MS MSD % Rec Max
Parameter Units Result Conc. Conc. Result Result °Ao Rec % Rec Limits RPD RPD Qual
Chemical Oxygen Demand mg/L 38.8 100 100 140 145 101 106 90-110 3 3
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 3421377 3421378
MS MSD
92565014003 Spike Spike MS MSD MS MSD °A, Rec Max
Parameter Units Result Conc. Conc. Result Result % Rec % Rec Limits RPD RPD Qual
Chemical Oxygen Demand mg/L 36.5 100 100 123 130 87 94 90-110 6 3 M1,R1
z
Fri)
w< rii
c) <
tro �, o'
A) NA
N3 et.
O a
n p
Results presented on this page are in the units indicated by the "Units" column except where an alternate unit is presented toe right of the result. 1
Date: 10/18/2021 11.58 AM
4
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QUALIFIERS
Project Weekly Effluent -Revised Report
Pace Project No 92562697
Pace Analytical Services, LLC
9800 Kincey Ave Suite 100
Huntersville, NC 28078
[phone]
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.
Reported results are not rounded until the final step prior to reporting. Therefore. calculated parameters that are typically reported as
"Total" may vary slightly from the sum of the reported component parameters.
Pace Analytical is TNI accredited. Contact your Pace PM for the current list of accredited analytes.
TNI - The NELAC Institute.
ANALYTE QUALIFIERS
D6 The precision between the sample and sample duplicate exceeded laboratory control limits.
M1 Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS) recovery
ML Matrix spike recovery and/or matrix spike duplicate recovery was below laboratory control limits. Result may be biased
low.
R1 RPD value was outside control limits.
Date 10/18/2021 11:58 AM
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QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: Weekly Effluent -Revised Report
Pace Project No.: 92562697
Pace Analytical Services, LLC
9800 KinceyAve Suite 100
Huntersville, NC 28078
[phone]
Lab ID
Sample ID QC Batch Method
Analytical
QC Batch Analytical Method Batch
92562697001 Effluent Comp SM 2540D-2011 649236
92562697001 Effluent Comp SM 5210B-2011 649085 SM 5210B-2011 649225
92562697002 Effluent Grab 1664E 1748696 EPA 1664B 1748696
92562697001 Effluent Comp SM 2540B-2011 649728
92562697001 Effluent Comp EPA 350.1 Rev 2.0 1993 650801
92562697001 Effluent Comp SM 5220D-2011 652495 SM 5220D-2011 652767
Date: 10/18/2021 11:58AM
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/
Document Name:
Sample Condition Upon Recelpt(SCUR)
Document Revised: October 28, 2020
Page 1 of 2
Document No.:
F-CAR-CS-033-Rev.07
Issuing Authority:
Pace Carolinas Quality Office
Laboratory receiving samples:
Asheville ❑ Eden❑ Greenwood ❑ Huntersville ❑ RaleighiMechanicsvilleD Atlanta[ Kernersvlferl
Sample Condition
upon Receipt
Courier.
❑ Commercial
Client Na e: V t'T- ' c' wo# : 92562697
1 Vq V e ieProject a
❑ d Ex ❑UPS ❑LISPS ❑Client IIlllhIIIIIIIfl III ill
[Pace [Other:_ 92662687
Custody Seal Present? Dyes 12 o Seals Intact? Des to
Packing Material: ❑Bubble Wrap Bubble Bags ❑None ❑ Other
Thermometer: ❑ IR Gun ID: JT'oc L'IWet ['Blue
Type of Ice:
Correction Factor: 0 �/1
Cooler Temp: 1 - 7 Add/Subtract CC) * V
Cooler Temp Corrected (' .
USDA Regulated Soil ( N/A, water sample)
Did samples originate in a quarantine zone within the United States: CA, NY, or SC (check maps)?
Date/Initials Person Examining Contents: 13 / I/
❑ Biological EINissue zen? 9/4, S ��
Yes No N/A _( O�
None
Temp should be above freezing to 6'C
❑Samples out of temp criteria. Samples on Ice, cooling process
has begun
Did samples originate from a foreign source ( ntemattonaily,
Including Hawaii and Puerto Rico ❑Yes Duo
Comments/Dlscrepancy:
Chain of Custody Present?
CC ❑No
ON/A
1.
Samples Arrived within Hold Time?
DN.
QN/A
2.
Short Hold Time Analysis (<72 hr.)?
Yes
°No
©N/A
3.
Rush Tum Around Time Requested?
Oyes
ko
DN/A
4.
Sufficient Volume?
es
No
N/A
5.
Correct Containers Used?
-Pace Containers Used?
Clits
°No
ONo
❑N/A
ON/A
6.
Containers Intact?
f
lies
❑No
AN/A
7.
Dissolved analysis: Samples Field Filtered?
©Y
©No
N/A
8.
Sample Labels Match COC?
-Includes Date/Time/ID/Analysis Matrix:
Yes
❑No
❑N/A
9.
Headspace in VOA Vials (>5-6mm)?
Oyes
•
i4I§A
10.
Trip Blank Present?
Trip Blank Custody Seals Present?
Des
:ties
_CINo
ONo
jNo
/
/A
11.
COMMENTS/SAMPLE DISCREPANCY
Field Data Required? Des ❑No
Lot ID of spilt containers:
CLIENT NOTIFICATION/RESOLUTION
Person contacted:
Project Manager SCURF Review:
Date/Time:
Date:
Project Manager SRF Review: Date:
Page 14 of 10

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Document Name:
Sample Condition Upon Receipt(SCURJ
Document Revised: October 28, 2020
Page 2 of 2
Document No.:
F-CAR-CS-033-Rev.07
Issuing Authority:
Pace Carolinas Quality Office
*Check mark top half of box if pH and/or dechlorination is
verified and within the acceptance range for preservation
samples.
Exceptions: VOA, Coliform, TOC, 011 and Grease, DR0/8015 (water) DOC, LLHg
**Bottom half of box is to list number of bottles
Projer' "
140#•92562697
PM: NWB Due Data: 10/06/21
CLIENT: 92WithersBRa
BP4U-125 mL Plastic Unpreserved (N/A) (CI-)
BP3U-250 mL Plastic Unpreserved (N/A)
BP2U-500 mL Plastic Unpreserved (N/A)
2
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BBP4S125 mL Plastic H2SO4 (pH < 2) (C1-)
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BP4Z-125 m1 Plastic ZN Acetate & NaOH (>9)
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WGFU-Wide-mouthed Glass jar Unpreserved
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AG3U-250 mL Amber Unpreserved (N/A) (a-)
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VG9T-40 mL VOA Na2S203 (N/A)
VG9U-40 mL VOA Unp (N/A)
OG9P-40 mL VOA H3PO4 (N/A)
VOAK (6 vials per kit)-5035 Idt (N/A)
V/W( (3 vials per kh)-VPH/Gas kit (N/A)
SPST 125 mi. Sterile Plastic (N/A— lab)
SP2T 250 ml Sterile Plastic (N/A — lab)
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069U-40 ml Amber Unpreserved vials (N/A)
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pH Adjustment Log for Preserved Samples
Sample ID
Type of preservative
pH upon receipt
Date preservation adjusted
Time preservation
adjusted
Amount of preservative
added
Lot 11
Note: Wheneve there is a discrepancy affecting North Carolina compliance samples, a copy of his form will he sent to the North Carolina DEHNR Certification Office (Le.
Out of hold, Incorrect preservative, out o temp, incorrect containers.
Raleigh Regional Office
Page 15 of 16

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