WQ0039473_Monitoring - 03-2022_20220504

• •
FORM:NDAR-1 10-13 NON-DISCHARGE APPLICATION REPORT(NDAR-1) Page of
Permit No.: WQ0039473 I Facility Name: Atkinson Milling Company I County: Johnston Month: / ,1 a diNL Year: �6.4a—
Field Name: Z1 Field Name: Z2 Field Name: Z3 Field Name:
Did irrigation occur
Area(acres): 0.52 Area(acres): 0.52 Area(acres): 0.52 Area(acres):
at this facility? Cover Crop: Mix Cover Crop: Mix Cover Crop: Mix Cover Crop:
Hourly Rate(in): 0.2 Hourly Rate(in): 0.2 Hourly Rate(in): 0.2 Hourly Rate(in):
Annual Rate(in): 15.1 Annual Rate(in): 15.1 Annual Rate(in): 15.1 Annual Rate(in):
Weather Freeboard Field Irrigated?Yes Field Irrigated?Yes Field Irrigated? Yes Field Irrigated?
4, 4 a, m °' v v v , E rn m � o of E rn a) 'D v c E T rn v � rn E
O N A OI N N at al >. C 7 ?' E E 8 al d T C 7 �` E E d a ..0. T E 7 E E a1 a) T C 7 _
A U `m .. m j u p! E m 3 E 3 g a E o 3 6 •a E as '- E o@ a E a, A E o
0 `m a °- $ 3 a R La o x o 0 3 a i- .` O o o 0 3 a P '� 0 o g x o 3 a i •E c o m S o
E ` N iv a .> Q J g = J > Q _ J 2 = J > Q _ J E J > Q J J
m H a 8 m
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°F in ft ft gal min in in gal min in in gal min in in gal min in in
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12 Month Floating Total(in):r ;� % % tI►•�=" m.3_ .....:<, ' .

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1) Page of
Did the application rates exceed the limits in Attachment B of your permit? No
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
Were all setbacks listed in your permit maintained for every application to each permitted site? Yes
Were all freeboards maintained in accordance with the specified freeboard heights in your permit? N/A
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
}t. /. N +,i o Aff—h-Mitinnal cheats if necessarv.
Operator in Responsible Charge (ORC) Certification
ORC: Andrew Wheeler
Certification No.: 1006226
Grade: Phone Number: 919-631-7572
Has It ce the previous NDAR-1? No
he O c anged sinLa___
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 Exp.: 4/30/23
VV
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.: W00039473 Facility Name: Atkinson Milling Company County: Johnston Month: /1 ctrcl Year: k. d-
PPI: Flow Measuring Point: Effluent Parameter Monitoring Point: Effluent
Parameter Code —► 50050
O
@ Q E I- in o
0 U O u
0
O O
24-hr hrs GPD
1 C%
2 0
3 C1
4 C
5
6
7 0
8 7c e ((
9 0
10 0
11 (.7
12 �1
13 (`
14
15 7 C C if 114177 _
16 7c.c,
17 C
18 C.)
19
20 0
21
22 7` c ! 4c V
i c,
23 c3
24
25 �f,9
26 0
27 0
28 0
29 c (I '1771
30 0
31 0
Average: (Dc't:
Daily Maximum:
Daily Minimum:
Sampling Type: /'i-ll
Monthly Avg. Limit: (1
Daily Limit:
Sample Frequency:

FORM:NDMR 03-12 NON-DISCHARGE MONITORING REPORT(NDMR) Page of_
Sampling Person(s) Certified Laboratories
Name: Andrew Wheeler Name: Microbac
Name: Name:
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
action(s)taken.Attach additional sheets if necessary.
Operator in Responsible Charge(ORC)Certification Permittee Certification
ORC: Andrew Wheeler Permittee: Atkinson Milling Company
Certification No.: 1006226 Signing Official: Andrew Wheeler
Grade: Phone Number: 919-631-7572 Signing Official's Title: Operations Manager
Has the ORC changed since the previous NDMR? No Phone Nu ber: 919-631-7572 Permit Expiration: 4/30/2023
Signature Date Signature Date
By this signature,I certify that this report is accurrate and complete to the best of my knowledge. 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

4micRoBAco
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2C0470
Project Description
Wastewater Sample
For:
Andrew Wheeler
Atkinson Milling Company
95 Atkinson Mill RD
Selma, NC 27576
Administration
Brittany Smith
Wednesday,April 13,2022
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 I Fayetteville, NC 28306 1910.864.1920 p I www.microbac.com
Page 1 of 9

OMICROBACk
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2C0470
Atkinson Milling Company Project Name:Wastewater Sample
Andrew Wheeler Project/PO Number: N/A
95 Atkinson Mill RD Received: 03/31/2022
Selma, NC 27576 Reported: 04/13/2022
Sample Summary Report
Sample Name Laboratory ID Client Matrix Sample Type Sample Begin Sample Taken Lab Received
Spray Tank, Grab K2C0470-01 Aqueous Grab 03/31/22 09:00 03/31/22 14:13
Page 2 of 9

KMICROBAC
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2C0470
Analytical Testing Parameters
1 Client Sample ID: Spray Tank,Grab
Sample Matrix: Aqueous Collected By: Andrew Wheeler
k Lab Sample ID: K2C0470-01 Collection Date: 03/31/2022 9:00
k Analyses Performed by: Microbac Laboratories, Inc. -Fayetteville
Microbiology Result RL Units DF Note Prepared Analyzed Analyst
SM 9222 D-2015
Fecal coliforms >60000 1.0 per 100mL 1 03/31/22 1528 04/01/22 1418 SXH
Inorganics Total Result RL Units DF Note Prepared Analyzed Analyst
Calculation
Total Nitrogen 49.2 1.00 mg/L 1 04/05/22 1700 WPR
EPA 351.2,Rv.2(1993)
Total Kjeldahl Nitrogen(TKN) 49.2 1.00 mg/L 1 04/05/22 1700 WPR
SM 2540 D-2015
Total Suspended Solids(TSS) 867 278 mg/L 111 04/05/22 1047 SXH
SM 4500-H+B-2011
pH(at 25°C) 6.0 1.0 S.U. 1 H 04/01/22 1155 SXH
SM 4500-NH3 G-2011
Ammonia as N 9.28 0.200 mg/L 1 04/01/22 1654 04/01/22 1654 WPR
SM 4500-P F-2011
Phosphorus as P 48 0.20 mg/L 1 04/12/22 1819 04/12/22 1819 WPR
SM 5210 B-2016
Biochemical Oxygen Demand(BOD5) 2830 2.00 mg/L 1 G1,G5 03/31/22 1527 04/05/22 1120 WPR
Analyses Performed by: Microbac Laboratories, Inc., Maryville
Inorganics Total Result RL Units DF Note Prepared Analyzed Analyst
EPA 300.0,Rv.2.1 (1993)
Nitrate as N <0.500 0.500 mg/L 5 04/01/22 1524 04/01/22 1524 CSE
Nitrite as N <0.500 0.500 mg/L 5 04/01/22 1524 04/01/22 1524 CSE
Microbac Laboratories,Inc.
2592 Hope Mills Rd I Fayetteville, NC 28306 I 910.864.1920 p I www.microbac.com Page 3 of 9

( MICROBACH
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2C0470
Batch Log Summary
Method Batch Laboratory ID Client/Source ID
EPA 300.0, Rv.2.1 (1993) 2214301 2214301-BLK1
2214301-BS1
2214301-MS1 R2D0086-02
2214301-MSD1 R2D0086-02
K2C0470-01 Spray Tank,Grab
Method Batch Laboratory ID Client/Source ID
SM 5210 B-2016 KC23110 K2C0470-01 Spray Tank,Grab
KC23110-BS 1
KC23110-DUP1 K2C0181-01
KC23110-BLK1
Method Batch Laboratory ID Client/Source ID
SM 4500-NH3 G-2011 KD20001 KD20001-BS1
K2C0470-01 Spray Tank,Grab
KD20001-DUP1 K2CO253-01
KD20001-MS1 K2CO253-01
Method Batch Laboratory ID Client/Source ID
SM 9222 D-2015 KD20004 KD20004-BLK1
KD20004-BS1
K2C0470-01 Spray Tank,Grab
Method Batch Laboratory ID Client/Source ID
SM 4500-H+B-2011 KD20005 K2C0470-01 Spray Tank,Grab
KD20005-DUP1 K2CO252-01
Method Batch Laboratory ID Client/Source ID
SM 2540 D-2015 KD20411 KD20411-BLK1
KD20411-DUP1 K2C0377-01
KD20411-BS1
K2C0470-01 Spray Tank,Grab
Method Batch Laboratory ID Client/Source ID
EPA 351.2, Rv.2(1993) KD20412 K2C0470-01 Spray Tank,Grab
KD20412-MS1 K2CO256-01
K020412-MSD1 K2CO256-01
Method Batch Laboratory ID Client/Source ID
SM 4500-P F-2011 KD20814 KD20814-MS2 K2D0059-02
KD20814-MS1 K2D0007-01
KD20814-MSD1 K2D0007-01
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
K2C0470
SM 4500-P F-2011 KD20814 KD20814-MSD2 K2D0059-02
KD20814-MS3 K2D0109-01
KD20814-MSD3 K2D0109-01
K2C0470-01 Spray Tank,Grab
Batch Quality Control Summary: Microbac Laboratories,Inc.-Fayetteville
Spike Source %REC RPD
Microbiology Result RL Units Level Result %REC Limits RPD Limit Notes
Batch KD20004-Wet Chem Aqueous-SM 9222 D-2015
Blank(KD20004-BLK1) Prepared:03/31/2022 Analyzed:04/01/2022
Fecal coliforms >Blank 1.0 per
initial 100mL
passed,
but the
blank final
failed
LCS(KD20004-BS1) Prepared:03/31/2022 Analyzed:04/01/2022
Fecal coliforms 3600 1.0 per 0-200
100mL
Spike Source %REC RPD
Inorganics Total Result RL Units Level Result %REC Limits RPD Limit Notes
Batch KC23110-Wet Chem Aqueous-SM 5210 B-2016
Blank(KC23110-BLK1) Prepared:03/31/2022 Analyzed:04/05/2022
Biochemical Oxygen Demand <2.00 2.00 mg/L
(BOD5)
LCS(KC23110-BS1) Prepared:03/31/2022 Analyzed:04/05/2022
Biochemical Oxygen Demand 136 mg/L 198 69 .59596-115.4
(BOD5)
Duplicate(KC23110-DUP1) Source:K2C0181-01 Prepared:03/31/2022 Analyzed:04/05/2022
Biochemical Oxygen Demand 210 2.00 mg/L 209 0.2 30
(BOD5)
Batch KD20001 -Wet Chem Aqueous-SM 4500-NH3 G-2011
LCS(KD20001-BS1) Prepared&Analyzed:04/01/2022
Ammonia as N 1.06 0.200 mg/L 1.00 106 90-110
Duplicate(KD20001-DUP7) Source:K2CO253-01 Prepared&Analyzed:04/01/2022
Ammonia as N 5.48 0.200 mg/L 5.66 3 10
Matrix Spike(KD20001-MS1) Source:K2CO253-01 Prepared&Analyzed:04/01/2022
Ammonia as N 6.99 0.200 mg/L 1.00 5.66 132 80-120
Batch KD20005-Wet Chem Aqueous-SM 4500-H+B-2011
Storm water,grabD(KD20005-DUP7) Source:K2CO252-01 Prepared&Analyzed:04/01/2022
pH(at 25°C) 5.3 1.0 S.U. 5.0 4 10
Batch KD20411 -Wet Chem Aqueous-SM 2540 D-2015
Microbac Laboratories,Inc.
2592 Hope Mills Rd I Fayetteville,NC 28306 1910.864.1920 p I www.microbac.com Page 5 of 9

< MICROBAC '
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2C0470
Spike Source %REC RPD
Inorganics Total Result RL Units Level Result %REC Limits RPD Limit Notes
Batch KD20411 -Wet Chem Aqueous-SM 2540 D-2015
Blank(KD20411-BLK1) Prepared&Analyzed:04/05/2022
Total Suspended Solids(TSS) <83.3 83.3 mg/L
LCS(KD20411-BS1) Prepared&Analyzed:04/05/2022
Total Suspended Solids(TSS) 88.7 2.50 mg/L 91.0 97 95-105
Duplicate(KD20411-DUP1) Source:K2C0377-01 Prepared&Analyzed:04/05/2022
Total Suspended Solids(TSS) 6380 500 mg/L 6540 2 10
Batch KD20412-Wet Chem Aqueous-EPA 351.2, Rv.2(1993)
Matrix Spike(KD20412-MS1) Source:K2CO256-01 Prepared&Analyzed:04/05/2022
Total Kjeldahl Nitrogen(TKN) 80.2 1.00 mg/L 5.00 43.4 738 90-110
Matrix Spike Dup(KD20412-MSD1) Source:K2CO256-01 Prepared&Analyzed:04/05/2022
Total Kjeldahl Nitrogen(TKN) 79.1 1.00 mg/L 5.00 43.4 715 90-110 1 10
Batch KD20814-Wet Chem Aqueous-SM 4500-P F-2011
Effluent,compositeS(KD20814-MS1) Source:K2D0007-01 Prepared&Analyzed:04/12/2022
Phosphorus as P 2.3 0.20 mg/L 2.0 0.46 94 90-110
Effluent,CompositeS(KD20814-MS2) Source:K2D0059-02 Prepared&Analyzed:04/12/2022
Phosphorus as P 2.3 0.20 mg/L 2.0 0.22 103 90-110
Effluent,CompositeS(KD20814-MS3) Source:K2D0109-01 Prepared&Analyzed:04/12/2022
Phosphorus as P 19 0.20 mg/L 2.0 16 116 90-110
Matrix Spike Dup(KD20814-MSD1) Source:K2D0007-01 Prepared&Analyzed:04/12/2022
Phosphorus as P 2.4 0.20 mg/L 2.0 0.46 97 90-110 2 200
Matrix Spike Dup(KD20814-MSD2) Source:K2D0059-02 Prepared&Analyzed:04/12/2022
Phosphorus as P 2.3 0.20 mg/L 2.0 0.22 104 90-110 0.8 200
Matrix Spike Dup(KD20814-MSD3) Source:K2D0109-01 Prepared&Analyzed:04/12/2022
Phosphorus as P 18 0.20 mg/L 2.0 16 86 90-110 3 200
Batch Quality Control Summary: Microbac Laboratories,Inc., Maryville
Spike Source %REC RPD
Inorganics Total Result RL Units Level Result %REC Limits RPD Limit Notes
Batch 2214301 -WetChem_IC-EPA 300.0, Rv.2.1 (1993)
Blank(2214301-BLK1) Prepared&Analyzed:04/01/2022
Nitrate as N <0.100 0.100 mg/L
Nitrite as N <0.100 0.100 mg/L
LCS(2214301-BS1) Prepared&Analyzed:04/01/2022
Nitrate as N 2.33 0.100 mg/L 2.26 103 90-110
Nitrite as N 10.6 0.100 mg/L 10.0 106 90-110
Matrix Spike(2214301-MS1) Source:R2D0086-02 Prepared&Analyzed:04/01/2022
Nitrate as N 39.8 2.24 mg/L 3.99 36.0 96.2 90-110
Microbac Laboratories,Inc.
2592 Hope Mills Rd I Fayetteville, NC 28306 1910.864.1920 p I www.microbac.com Page 6 of 9

( MICROBAC '
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2C0470
Spike Source %REC RPD
Inorganics Total Result RL Units Level Result %REC Limits RPD Limit Notes
Batch 2214301 -WetChem_IC-EPA 300.0, Rv.2.1 (1993)
Matrix Spike(2214301-MS1) Source:R2D0086-02 Prepared&Analyzed:04/01/2022
Nitrite as N 32.3 2.24 mg/L 17.6 15.5 95.6 90-110
Matrix Spike Dup(2214301-MSD1) Source:R2D0086-02 Prepared&Analyzed:04/01/2022
Nitrate as N 40.3 2.24 mg/L 3.99 36.0 110 90-110 1.34 20
Nitrite as N 32.3 2.24 mg/L 17.6 15.5 95.1 90-110 0.277 20
Definitions
B9: Target analyte is detected in the method blank at or above the method detection limit but below the method reporting
limit.
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.
H: Analyte was prepared and/or analyzed outside of the analytical method holding time
mg/L: Milligrams per Liter
NAD: Normalized Absolute difference
RL: Reporting Limit
RPD: Relative Percent Difference
S.U.: Standard Units
Cooler Receipt Log
Cooler ID: Default Cooler Temp: 18.6°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
Microbac Laboratories, Inc., Maryville
678 NC Dept.of Environmental Quality
Microbac Laboratories,Inc.
2592 Hope Mills Rd I Fayetteville, NC 28306 1910.864.1920 p I www.microbac.com Page 7 of 9

(.1 ) MICROBAC '
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2C0470
Report Comments
Reviewed and Approved By:
Samples were received in proper condition and the reported results conform to j^
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<https://www.microbac.com/standard-terms-conditions>. Reported: 04/13/2022 18:20
Microbac Laboratories,Inc.
2592 Hope Mills Rd I Fayetteville, NC 28306 1910.864.1920 p I www.microbac.com Page 8 of 9

Microbac-Fayetteville SHORT HOLDS ACCEPTED IvIONDAY- THURSDAY UNTIL . *K2C0470*
rCHAIN OF (
1 ! ��ROBAG Fa3e Hope Milis Rd. Number 201111
Fayetteville, NC 28306 Instructions
_ — — — — TO BE COMA
,ii.9\ Turnaround Time
Lab Report Address <is 6�f'T111 -5'-. �2iv C,-,in Cliente Name:
Address �� t i Koutine (5 to i uusiness says)Temp. Upon Receipt(sC) I$�� Therm ID
Client Name: �ry1.7C� lNli�lt7� Name:
Address: C3S 11 P150.4 /KM�v
p } [] RUSH*(notify lab) Holding TimeAddress:
City,State,Zi( Woe- t et)L i a'75�0 City,State,Zip
(needed by) Samples Received on Ice? Yes No N/A
y lid
l Report Type Custody Seals Intact? Yes No N/A
Contact: �ppr't'w W Contact:
Telephone No.
q L 9 43 t -7Sj7D- Telephone N .: Results Only [ ] Level 1 -[ ] Level 2 [ ] Level3 [ ]Level 4 [ ] EDO
Send Report via( j Mail [ )Fax [u a-mail LZ..L.);A .e �F'de—ry4.411 Ck •Send Invoice vi ( )Mail [ I Fax [-)a-mail �,f
Location: 1 c M � 4'L5• ii) Z .[►
PO No.: Compliance Monitoring? �I Yes [ I No [ ]Agency/Program
Project: / _
Lee-sampler Signature: ;ampler Phone No.: q te L✓0 t 75-7, -
Sampled by(PRINT): ��h"' _ amp - -
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
REQUESTED ANALYSIS / 1
I / / I / / / l l I /r i / k / 1 1
Grab / / / 1 / i 1 '�l l / r / / /a / / r
No. of Preservative r y� + / r r O + Z r Q'r r r 1 , J r / Additional Notes
•
Date Time OY ! \e?/ l'n/ r v-1 "r r r + +
Lab ID Client Sample ID Container atrix ** type t r� .- - G� :�/k/ / r / ! / r
Collected Collected ' + ` �' ••r �' r ' r ' + + r I '
5 Comp - [' r �I/ • / i'" �/ / / I / / , r ;
0\ Spy`'( (_ 3
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tl
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N.
)
I 1
Sam C] Di •ose as appropriat turn . ]Archive
Possible Hazard Identifi< [] Hazardous [] N n-Hazardous [] Radioactive - —
Comments t, -atu• j3 - c(�t . -,,'. �J
3 Date/TimP ` ived ture ,
�R ngwshed By{signature) ` 45-
_- •-„- i•n.t' ., m+ ..;.4.,-. ,mP
To
Rel. ,wished By(si nature) Date/Time ,�� � - „( � (!�
'�.J a 63. 31 ja 0. - ( i -...... .- . ` . _...
e B - na " -T_ Re eived By(signetIiii •;Relinquished By (signature) Date/Time I Page 9 Of 9
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