NCG030669_Monitoring Report_20220329

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG030000 -N-
Metal Fabrication
Click here for instructions
Complete, sign, scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report (DM'0} Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate Dt<'tVil�.R,Regional Office.
Certificate of Coverage No. NCG03 06
Person Collecting Samples: AV1_?1"/e j WFAIS-L Cl
Facility Name: /{ C % L / 'T Y
Laboratory Name: 1PACC is /1,eyTr G/1 L
Facility County: R V W4
Laboratory Cert. No.: D . ' %OG�
Discharge during this period:
Yes E]No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances? Yes ONo
If so, which Tier (I, II, or III)?
A copy of this DMR has been uploaded electronically via https://edocs.deg.nc.gov/Forms/SW-DMR Yes No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities — Benchmarks in (Red)
Parameter
Code
Parameter
Outfall % Q
Outfall
Outfall
Outfall
Outfall
N/A
Receiving Stream Class
C
C
N/A
Date Sample Collected MM/DD/YYYY
03 /fo e&.?
46529
24-Hour Rainfall in inches
Qa <-+
C0530
TSS in mg/L (100 or 50*)
C' 2 S �.��L
2. 5-'" 2
00400
pH in standard units (6.0-9.0 FW,
T ��
6.8-8.5SW)
01119
al le in mg/L
(0.010 FWt0.0058 SW)
+GG'�t�
01051
Lead, total recoverable in mg/ L
rn
�s
< 003-0 m�
(0.075 FW, 0.22 SW)
/
01094
Zinc, total recoverable in mg/ L (0.126
�°
FW, 0.095 SW)
.v/Cyr➢
00340
Chemical Oxygen Demand (COD) in
<,/n�
m'/
00552
Non -Polar Oil & Grease in mg/L (15)
< 9 %V11
< 5- U ir�z
* Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of 50 mg/L. All other water classifications have a benchmark of 100 mg/L
FW (Freshwater) SW (Saltwater)
Notes (optional):
"I certify by my signature below, 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 qualified personnel properly gather and evaluate 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."
Signature of Permittee or Delegated Authorized Individual
1 �t «� f 1'✓��CC1? - Y ti'�^QC �1f'�r�' Ce
ail Address
Z �C) L,
Date
I/ fI_S /1
Phone Number

aceAnalytical
www.pacelabs.cem
March 24, 2022
Robert Hensley
Agility Fuel Systems
1010 Corporate Center Drive
Salisbury, NC 28146
RE: Project: 1ST QUARTER STORMWATER
Pace Project No.: 92594346
Dear Robert Hensley:
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
RECEIVED
MAR 29 M22
UENK-DEMLR
Land Quality Section
Mooresville Regional Office
Enclosed are the analytical results for sample(s) received by the laboratory on March 18, 2022. 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 Analytical Services - Asheville
• Pace Analytical Services - Charlotte
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
Tyriek Hooks
tyriek. hooks@pace labs. com
[phone]
Project Manager
Enclosures
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 1 of 14

aceAnalytical
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Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Project: 1ST QUARTER STORMWATER
Pace Project No.: 92594346
Pace Analytical Services Charlotte
South Carolina Laboratory ID: 99006
9800 Kincey Ave. Ste 100, Huntersville, NC 28078
North Carolina Drinking Water Certification #: 37706
North Carolina Field Services Certification #: 5342
North Carolina Wastewater Certification #: 12
South Carolina Laboratory ID: 99006
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804
Florida/NELAP Certification #: E87648
North Carolina Drinking Water Certification #: 37712
North Carolina Wastewater Certification #: 40
CERTIFICATIONS
South Carolina Certification #: 99006001
South Carolina Drinking Water Cert. #: 99006003
Florida/NELAP Certification #: E87627
Kentucky UST Certification #: 84
Louisiana DoH Drinking Water #: LA029
VirginiaNELAP Certification #: 460221
South Carolina Laboratory ID: 99030
South Carolina Certification M 99030001
VirginiaNELAP Certification #: 460222
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services, LLC. Page 2 of 14

aceAnalytical
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SAMPLE ANALYTE COUNT
Pace Analytical Services, LLC
9800 KinceyAve. Suite 100
Huntersville, NC 28078
[phone]
Project:
Pace Project No.:
1ST QUARTER STORMWATER
92594346
Analytes
Lab ID
Sample ID
Method
Analysts
Reported
Laboratory
92594346001
OUTFALL 2 GRAB
EPA 1664E
ICO
1
PASI-C
EPA 200.7 Rev 4.4 1994
KH
3
PASI-A
SM 2540D-2015
MA62
1
PASI-A
SM 5220D-2011
JP1
1
PASI-A
92594346002
OUTFALL 1B GRAB
EPA 1664B
ICO
1
PASI-C
EPA 200.7 Rev 4.4 1994
KH
3
PASI-A
SM 254OD-2015
MAB2
1
PASI-A
SM 5220D-2011
JP1
1
PASI-A
PASI-A = Pace Analytical Services -Asheville
PASI-C = Pace Analytical Services - Charlotte
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services, LLC. Page 3 of 14

aceAnalytical
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ANALYTICAL RESULTS
Project: 1ST QUARTER STORMWATER
Pace Project No.: 92594346
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Sample: OUTFALL 2 GRAB
Lab ID: 92594346001 Collected: 03/16/22 17:00
Received: 03/18/22 14:00 Matrix: Water
Parameters
Results Units Report Limit DF
Prepared Analyzed CAS No. Qual
1664 SGT-HEM, TPH
Analytical Method: EPA 1664E
Pace Analytical Services - Charlotte
Total Petroleum Hydrocarbons
ND mg/L 5.0 1
03/21/22 23:53
200.7 MET ICP
Analytical Method: EPA 200.7 Rev 4.4 1994 Preparation
Method: EPA 200.7 Rev 4.4 1994
Pace Analytical Services -Asheville
Copper
ND ug/L 5.0 1
03/19/22 18:47 03/21/22 22:35 7440-50-8
Lead
ND ug/L 5.0 1
03/19/22 18:47 03/21/22 22:35 7439-92-1
Zinc
ND ug/L 10.0 1
03/19/22 18:47 03/21/22 22:35 7440-66-6
2540D Total Suspended Solids
Analytical Method: SM 2540D-2015
Pace Analytical Services - Asheville
Total Suspended Solids
ND mg/L 2.5 1
03/21/22 13:06
5220D COD
Analytical Method: SM 5220D-2011 Preparation Method: SM 5220D-2011
Pace Analytical Services - Asheville
Chemical Oxygen Demand
ND mg/L 25.0 1
03/24/22 01:42 03/24/22 04:46
Date: 03/24/2022 05:09 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 4 of 14

aceAnalytical
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ANALYTICAL RESULTS
Project: 1ST QUARTER STORMWATER
Pace Project No.: 92594346
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Sample: OUTFALL 1B GRAB
Lab ID: 92594346002 Collected: 03/16/22 18:00
Received: 03/18/22 14:00 Matrix: Water
Parameters
Results Units Report Limit DF
Prepared Analyzed CAS No. Qua[
1664 SGT-HEM, TPH
Analytical Method: EPA 1664B
Pace Analytical Services - Charlotte
Total Petroleum Hydrocarbons
ND mg/L 4.9 1
03/21/22 23:53
200.7 MET ICP
Analytical Method: EPA 200.7 Rev 4.4 1994 Preparation
Method: EPA 200.7 Rev 4.4 1994
Pace Analytical Services -Asheville
Copper
ND ug/L 5.0 1
03/19/22 18:47 03/21/22 22:38 7440-50-8
Lead
ND ug/L 5.0 1
03/19/22 18:47 03/21/22 22:38 7439-92-1
Zinc
ND ug/L 10.0 1
03/19/22 18:47 03/21/22 22:38 7440-66-6
2540D Total Suspended Solids
Analytical Method: SM 2540D-2015
Pace Analytical Services - Asheville
Total Suspended Solids
ND mg/L 2.5 1
03/21/22 13:06
5220D COD
Analytical Method: SM 5220D-2011 Preparation Method: SM 5220D-2011
Pace Analytical Services - Asheville
Chemical Oxygen Demand
ND mg/L 25.0 1
03/24/22 01:42 03/24/22 04:46
Date: 03/24/2022 05:09 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 5 of 14

aceAnalytical
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QUALITY CONTROL DATA
Project: 1ST QUARTER STORMWATER
Pace Project No.: 92594346
QC Batch: 686269 Analysis Method: EPA 1664B
QC Batch Method: EPA 1664B Analysis Description: 1664 SGT-HEM, TPH
Laboratory: Pace Analytical Services - Charlotte
Associated Lab Samples: 92594346001, 92594346002
METHOD BLANK: 3588125 Matrix: Water
Associated Lab Samples: 92594346001, 92594346002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Petroleum Hydrocarbons mg/L ND 5.0 03/21/22 23:53
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
LABORATORY CONTROL SAMPLE:
3588126
Spike
LCS
LCS
% Rec
Parameter
Units
Conc.
Result
% Rec
Limits
Qualifiers
Total Petroleum Hydrocarbons
mg/L
20
17.8
89
64-132
MATRIX SPIKE SAMPLE:
3588127
92594214001
Spike
MS
MS
% Rec
Parameter
Units
Result
Conc.
Result
% Rec
Limits Qualifiers
Total Petroleum Hydrocarbons
mg/L
ND 20
14.4
66
64-132
SAMPLE DUPLICATE: 3588128
35704294001
Dup
Parameter
Units
Result
Result
RPD
Qualifiers
Total Petroleum Hydrocarbons
mg/L
5.OU
ND
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.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 03/24/2022 05:09 PM without the written consent of Pace Analytical Services, LLC. Page 6 of 14

aceAnaIXical
www.pacelabs.com
QUALITY CONTROL DATA
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Project: 1 ST QUARTER STORMWATER
Pace Project No.: 92594346
QC Batch: 685960
Analysis Method: EPA 200.7 Rev 4.4 1994
QC Batch Method: EPA 200.7 Rev 4.4 1994
Analysis Description: 200.7
MET
Laboratory: Pace Analytical Services - Asheville
Associated Lab Samples: 92594346001, 92594346002
METHOD BLANK: 3586865
Matrix: Water
Associated Lab Samples: 92594346001, 92594346002
Blank Reporting
Parameter Units
Result Limit
Analyzed Qualifiers
Copper ug/L
ND 5.0
03/21/22 21:18
Lead ug/L
ND 5.0
03/21/22 21:18
Zinc ug/L
ND 10.0
03/21/22 21:18
LABORATORY CONTROL SAMPLE: 3586866
Spike LCS
LCS % Rec
Parameter Units
Conc. Result
% Rec Limits Qualifiers
Copper ug/L
500 505
101 85-115
Lead ug/L
500 485
97 85-115
Zinc ug/L
500 476
95 85-115
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 3586867
3586868
MS MSD
92593976001
Spike Spike MS
MSD MS MSD
% Rec
Parameter Units Result
Conc. Conc. Result
Result % Rec % Rec
Limits
RPD Qual
Copper ug/L 69.8
500 500 586
585 103 103
70-130
0
Lead ug/L ND
500 500 444
447 88 89
70-130
1
Zinc ug/L 238
500 500 708
714 94 95
70-130
1
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 3586869 3586870
MS MSD
92594264001
Spike Spike MS
MSD MS MSD
% Rec
Parameter Units Result
Conc. Conc. Result
Result % Rec % Rec
Limits
RPD Qual
Copper ug/L ND
500 500 494
491 99 98
70-130
1
Lead ug/L ND
500 500 482
479 96 96
70-130
1
Zinc ug/L 114
500 500 588
584 95 94
70-130
1
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.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 03/24/2022 05:09 PM without the written consent of Pace Analytical Services, LLC. Page 7 of 14

aceAnalytical
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QUALITY CONTROL DATA
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Project: 1ST QUARTER STORMWATER
Pace Project No.: 92594346
QC Batch: 686030
Analysis Method:
SM 2540D-2015
QC Batch Method: SM 2540D-2015
Analysis Description:
2540D Total Suspended Solids
Laboratory:
Pace Analytical Services -Asheville
Associated Lab Samples: 92594346001, 92594346002
METHOD BLANK: 3587064
Matrix:
Water
Associated Lab Samples: 92594346001, 92594346002
Blank
Reporting
Parameter
Units
Result
Limit
Analyzed Qualifiers
Total Suspended Solids
mg/L
ND
2.5 03/21/22 13:05
LABORATORY CONTROL SAMPLE:
3587065
Spike
LCS
LCS % Rec
Parameter
Units
Conc.
Result
% Rec Limits Qualifiers
Total Suspended Solids
mg/L
250
244
98 90-110
SAMPLE DUPLICATE: 3587261
92594270001
Dup
Parameter
Units
Result
Result
RPD Qualifiers
Total Suspended Solids
mg/L
251
266 6
SAMPLE DUPLICATE: 3587262
92594330001
Dup
Parameter
Units
Result
Result
RPD Qualifiers
Total Suspended Solids
mg/L
126
107 16
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.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 03/24/2022 05:09 PM without the written consent of Pace Analytical Services, LLC. Page 8 of 14

aceAnalj cal
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QUALITY CONTROL DATA
Project: 1ST QUARTER STORMWATER
Pace Project No.: 92594346
QC Batch: 686575 Analysis Method: SM 5220D-2011
QC Batch Method: SM 5220D-2011 Analysis Description: 5220D COD
Laboratory: Pace Analytical Services -Asheville
Associated Lab Samples: 92594346001, 92594346002
METHOD BLANK: 3589466 Matrix: Water
Associated Lab Samples: 92594346001, 92594346002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Chemical Oxygen Demand mg/L ND 25.0 03/24/22 04:40
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
LABORATORY CONTROL SAMPLE: 3589467
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Chemical Oxygen Demand mg/L 750 766 102 90-110
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 3589468 3589469
MS MSD
92593813003 Spike Spike MS MSD MS MSD % Rec
Parameter Units Result Cone. Conc. Result Result % Rec % Rec Limits RPD Qua[
Chemical Oxygen Demand mg/L 26.5 100 100 130 125 103 99 90-110 4 R1
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 3589470 3589471
MS MSD
92593813006 Spike Spike MS MSD MS MSD % Rec
Parameter Units Result Conc. Cone. Result Result % Rec % Rec Limits RPD Qual
Chemical Oxygen Demand mg/L ND 100 100 121 121 112 112 90-110 0 M1
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.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 03/24/2022 05:09 PM without the written consent of Pace Analytical Services, LLC.
Page 9 of 14

aceAnalXical
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QUALIFIERS
Project: 1 ST QUARTER STORMWATER
Pace Project No.: 92594346
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.
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
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
M 1 Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS) recovery.
R1 RPD value was outside control limits.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 03/24/2022 05:09 PM without the written consent of Pace Analytical Services, LLC. Page 10 of 14

FaceAnalytical
www.pacelabs.com
,
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: 1ST QUARTER STORMWATER
Pace Project No.: 92594346
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Lab ID
Sample ID
QC Batch Method
QC Batch
Analytical Method
Analytical
Batch
92594346001
OUTFALL 2 GRAB
EPA 1664B
686269
92594346002
OUTFALL I GRAB
EPA 1664B
686269
92594346001
OUTFALL 2 GRAB
EPA 200.7 Rev 4.4 1994
685960
EPA 200.7 Rev 4.4 1994
685977
92594346002
OUTFALL 1 B GRAB
EPA 200.7 Rev 4.4 1994
685960
EPA 200.7 Rev 4.4 1994
685977
92594346001
OUTFALL 2 GRAB
SM 2540D-2015
686030
92594346002
OUTFALL 1B GRAB
SM 2540D-2015
686030
92594346001
OUTFALL 2 GRAB
SM 5220D-2011
686575
SM 5220D-2011
686901
92594346002
OUTFALL I GRAB
SM 5220D-2011
686575
SM 5220D-2011
686901
Date: 03/24/2022 05:09 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 11 of 14

Documeht.Nanie: Document Revised: November 15,2021
hd Sample Condition Upon Recefpt(SCU(i), pa e,1 of 2
aCeAr lye c(C�l Documet No;; Issuing Authority;
^�_ F•CAR•t 5•t)33•Rev:OB Pace Caro)ima QualitYOHlce
t.ebora ory receiving samples:
Asheville (1 Eden❑ Greenwood n Huntersville C] Raleigh[] Mechanlesville❑ Atlanta❑' KernersyilleF�
Client Nastte; Project#:WO# : 92;594346
9�L�t� F`,P% St,s�r.� s
courier: ed Esc$ �1 ❑Client II' II" IIII'I' II (I I'I)
©:Cortim. eroal El Pace
92594:346
Custody Seat Present? Dyes ®No Seals,itttact? ❑Yes MNo -
Packing Materiel; ❑Bub.bie Wrap. VIBUbbie Bags ❑None ❑ Pther
Thermorfieter:
� IR run xv, 93 / 0% / ®4Vet ❑glue
Type.uf ice:
^CQUection Factor:
COON?TerMpt © Atid/Subtract ('C)
CbalerIemp Corrected ('C):
USt)A Regul@ted Soll Q N/A, water sample)
Did samples originate to a quarantine tone within the United States: CA, NY, or SC (cheek mops)?
d'iVnc rANn
Dale/IrilUalsPerson:ExarriiningCaritent9;.1 �(/-�.z-/�/{
Biological Tissue Prozon?
❑ye's (lNo MNJA
nNonr,
Temp should be above freezing to 6°C
[]5emplos Out of lemp criteria. 5bm ples on kq, coaling pmcess
hat begun
Did sainpiei ollglnutefrdm a lorefgn source pnternatlanaliy,
CPiTurn /Dls repancy_
--
Chalri of6ustod .Present?
ONa.
❑4/A
1
Sa nip fasArOvedwithin HoicITlme710yes
. No ....
❑N'q
2,
shpit bold Ttme Anal sis <72 hr.)?
(QYes .EbNo
Qq1A
3:
ttuiliTutn.ArooOdThneRogtlested7
Yes. No
tIN/A
4.
SuffoentVnluRm7,_ `_
Yes_❑No N A
_5, _
CorrdatC.opcainers Used?
Pace t ontainers Used?..
Myos; ❑Na Qti/A
Yes .: (]No.. .. (JN/A
S
_..
Dissolved analysis; Sample's field Filtered?
_ Yes No
N A
8,
Santpita Labels Match Cbe?
irteludes gate/time/ID/Analysis Matrix:.
(
(7-�- Yes QNo
W !
DN/A
9.
Plead$ pace In VUA VWs (>S-6mm)?
Yes rJNo
N/A
10.
11,
Trip 61ankPresent? ❑yes [INo [ jN/A
Trip Blanktgstody5palsPresent? QYes ❑Na N/A
COMMENTS/SAMPLE DISGREDANCY
Field Data Required? ❑*s (].No
Lot ID of spliteofltaifters
CLIENT NOTIFICATION/RESOLUTION — —
Person contacted:
Project Manager.SCURF Review;
Project Manager SRF Review:
Date/Tfine:
Date:
Date.
Page 12 of 14

ant Naive:
No,:
"Check mark top half of box. if pH and/or dechiorination is
verified and.within the'acceptance range for preservation
samples,
Extepglorts;VOA; Coliform;_:TOC, Oil ddd Grease, DRO/8025 (wktfr) 00C,. LLHg
*'Bottohrhalf of, box ls,to list number of Bottles
Document Revised: November
Pake2 of 2
ParF.[arollnas Oualliv Office
Project # W01t : 92594346
PM: T:iH Due Dale: 03/25/22
CLIENT: 92-Agility F
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adjusted
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Note: Whenever there Is a dhcrepancy affecting North Carolina compliance samples, a Copy of this form will be sentto the North_Coolina QEtINR Certifination Office(i.e.
Out of'hold, Incorrect.preseivative, out of temp., incorrect containers,
Page 13 of 14

ITEM #
a
P
, i A
o
0
(n
IN
V
Sr
0 :E
'R
MATRO(COM
SAMPE TYPE (GaGRAB C=CO,%!P)
0
>
cn
0
SAMPI If -L'PATCCLILECTION
A
FV
112SO4
z
HNO3
iF
8'
I IW
Moll
Na2,1320
(D
CA
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Ed
1
0:1101
7
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Ti N F
3.
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TSS
tp
1664 OJ rml G!9m
mstsis by 203.7
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Rouidtful Cli'cdno (YIN)
y
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(YIN)
cuslody
Sunled
co ter
.Y/N)
A
samrifig
n1act
__A_LL__L
i
1
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1
Page 14 of 14