NCG030669_2022 DMR_20221019

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report(DMR) Form for NCG030000
Metal Fabrication
Click here for instructions
Complete,sign,scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report(DMR) Upload form within
30 days of receiving sampling results. Mail the original,signed hard copy of the DMR to the appropriate DEMLR Regional Office.
Certificate of Coverage No. NCG03 Q&l0 9 Person Collecting Samples: H /(/$L f y
Facility Name: r $ M FG L C Laboratory Name: 1-2A CC /4 IV14 L Y T J C,4 L
Facility County: Ro W/4 /V Laboratory Cert. No.: D `770 3 7/ C 3$I
Discharge during this period:1Z Yes No (if no,skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances? Yes RNo
If so,which Tier(I, ll,or III)? I
A copy of this DMR has been uploaded electronically via https://edocs.deg.nc.gov/Forms/SW-DMR Lj Yes Lj No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities—Benchmarks in(Red)
Parameter Parameter Outfall J5 Outfall 2 Outfall Outfall Outfall
Code
N/A Receiving Stream Class G C,
N/A Date Sample Collected MM/DD/YYYY O f p 202 09 30 2022
46529 24-Hour Rainfall in inches 2.65if 2.65.1
C0530 TSS in mg/L(100 or 50*) 3. 1 my l 2.9 1"9 1
00400 pH in standard units(6.0-9.0 FW,
6.8-8.5 SW) �'
01119 Copper,total recoverable in mg/L O,0o61 rn�
(0.010 FW,0.0058 SW) L L
01051 Lead,total recoverable in mg/L DO/0 rnj < 00/0 rn�
(0.075 FW,0.22 SW) L L
01094 Zinc,total recoverable in mg/L(0.126 ( "0i/9
FW,0.095 SW)
00340 Chemical Oxygen Demand(COD) in < 25, < ZS V
mg/L(120) L 7
00552 Non-Polar Oil&Grease in mg/L(15) C 4,, 9 "'�y G¢;9
* 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."
5 Z Z
Signatu PerKhitfK or Delegated Authorized Individual Date
Doti. ��.Jdy --411 A ,., . coM 70y- s 70-36 13
Email Address Phone Number

Pace Analytical Services,LLC
aceAnalytical 9800 Kiney Ave. Suite 100
Huntersville,NC 28078078
www.pacllabs.com [phone]
October 14, 2022
Robert Hensley
Agility Fuel Systems
1010 Corporate Center Drive
Salisbury, NC 28146
RE: Project: STORMWATER 3RD QUARTER
Pace Project No.: 92629171
Dear Robert Hensley:
Enclosed are the analytical results for sample(s) received by the laboratory on October 04, 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
• Pace Analytical Services-Peachtree Corners, GA
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
p -
Tyriek Hooks
[e-mail]
[phone]
Project Manager
Enclosures
/r 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 15
6, j

Pace Analytical Services,LLC
9800 Kincey Ave. Suite 100
laneAnalj&cal" Huntersville,NC 28078
www.pacelabs.com [phone]
CERTIFICATIONS
Project: STORMWATER 3RD QUARTER
Pace Project No.: 92629171
Pace Analytical Services Charlotte
South Carolina Laboratory ID:99006 South Carolina Certification#:99006001
9800 Kincey Ave.Ste 100,Huntersville,NC 28078 South Carolina Drinking Water Cert.#:99006003
North Carolina Drinking Water Certification#:37706 Florida/NELAP Certification M E87627
North Carolina Field Services Certification#:5342 Kentucky UST Certification#:84
North Carolina Wastewater Certification#:12 Louisiana DoH Drinking Water#:LA029
South Carolina Laboratory ID:99006 VrginiaNELAP Certification#:460221
Pace Analytical Services Asheville
2225 Riverside Drive,Asheville,NC 28804 South Carolina Laboratory ID:99030
Florida/NELAP Certification#:E87648 South Carolina Certification#:99030001
North Carolina Drinking Water Certification#:37712 VrginiaNELAP Certification M 460222
North Carolina Wastewater Certification#:40
Pace Analytical Services Peachtree Corners
110 Technology Pkwy,Peachtree Corners,GA 30092 North Carolina Certification#:381
Florida DOH Certification#:E87315 South Carolina Certification#:98011001
Georgia DW Inorganics Certification M 812
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
without the written consent of Pace Analytical Services,I.I.C. Page 2 of 15

Pace Analytical Services,LLC
aceAnalytical a 9800 Kinsey Ave. Suite100
Hunlersville,NC 28078078
www.pacelabs.com [phone]
SAMPLE ANALYTE COUNT
Project: STORMWATER 3RD QUARTER
Pace Project No.: 92629171
Anatytes
Lab ID Sample ID Method Analysts Reported Laboratory
92629171001 OUTFALL 1B EPA 1664B REL 1 PASI-C
EPA200.8 CW1 3 PAS]-GA
SM 2540D-2015 CS1 1 PASI-A
SM 5220D-2011 JMH1 1 PASI-A
92629171002 OUTFALL 2 EPA 1664B REL 1 PASI-C
EPA 200.8 CW1 3 PASI-GA
SM 254OD-2015 CS1 1 PASI-A
SM 5220D-2011 JMH1 1 PASI-A
PASI-A=Pace Analytical Services-Asheville
PASI-C=Pace Analytical Services-Charlotte
PASI-GA=Pace Analytical Services-Peachtree Corners,GA
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
without the written consent of Pace Analytical Services,LLC. Page 3 of 15

Pace Analytical Services,LLC
aceAnalytical® 9800 Kincey Ave. Suite 100
Huntersville,NC 28078
www.pacelabs.com [phone]
SUMMARY OF DETECTION
Project: STORMWATER 3RD QUARTER
Pace Project No.: 92629171
Lab Sample ID Client Sample ID
Method Parameters Result Units Report Limit Analyzed Qualifiers
92629171001 OUTFALL I
EPA 200.8 Copper 6.1 ug/L 5.0 10/14/22 00:18
EPA 200.8 Zinc 11.9 ug/L 10.0 10/14/22 00:18
SM 254OD-2015 Total Suspended Solids 3.1 mg/L 2.5 10/05/22 15:01
92629171002 OUTFALL 2
EPA 200.8 Copper 6.4 ug/L 5.0 10/14/22 00:24
EPA 200.8 Zinc 12.4 ug/L 10.0 10/14/22 00:24
SM 254OD-2015 Total Suspended Solids 2.9 mg/L 2.5 10/05/22 15:02
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 15

Pace Analytical Services,LLC
aceAnalytical o 9800 Kiney Ave. Suite 100
Huntersville,NC 28078078
www.pacelabs.com [phone]
ANALYTICAL RESULTS
Project: STORMWATER 3RD QUARTER
Pace Project No.: 92629171
Sample: OUTFALL 113 Lab lD: 92629171001 Collected: 09/30/22 13:00 Received: 10/04/22 12:10 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
1664 SGT-HEM,TPH Analytical Method:EPA 1664B
Pace Analytical Services-Charlotte
Total Petroleum Hydrocarbons ND mg/L 4.9 1 10/11/22 03:15
200.8 ATL ICPMS,NC Analytical Method:EPA 200.8 Preparation Method:EPA 200.8
Pace Analytical Services-Peachtree Corners,GA
Copper 6.1 ug/L 5.0 1 10/13/22 14:29 10/14/22 00:18 7440-50-8
Lead ND ug/L 1.0 1 10/13/22 14:29 10/14122 00:18 7439-92-1
Zinc 11.9 ug/L 10.0 1 10/13/22 14:29 10/14/22 00:18 7440-66-6
2540D Total Suspended Solids Analytical Method:SM 2540D-2015
Pace Analytical Services-Asheville
Total Suspended Solids 3.1 mg/L 2.5 1 10/05/22 15:01
5220D COD Analytical Method:SM 52200-2011 Preparation Method:SM 5220D-2011
Pace Analytical Services-Asheville
Chemical Oxygen Demand ND mg/L 25.0 1 10/05/22 11:28 10/05/22 17:03
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
Date: 10/14/2022 03:17 PM without the written consent of Pace Analytical Services,LLC, Page 5 of 15

Pace Analytical Services,LLC
9800 Kincey Ave. Suite 100
laneAnalXicaf' Huntersville,NC 28078
www.pacelabs.com (704)875-9D92
ANALYTICAL RESULTS
Project: STORMWATER 3RD QUARTER
Pace Project No.: 92629171
Sample: OUTFALL 2 Lab ID: 92629171002 Collected: 09/30/22 14:00 Received: 10/04/22 12:10 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 mg1L 4.9 1 10/11/22 03A5
200.8 ATL ICPMS,NC Analytical Method:EPA 200.8 Preparation Method:EPA 200.8
Pace Analytical Services-Peachtree Corners,GA
Copper 6.4 ug/L 5.0 1 10/13/22 14:29 10/14/22 00:24 7440-50-8
Lead ND ug/L 1.0 1 10/13/22 14:29 10/14/22 00:24 7439-92-1
Zinc 12.4 ug/L 10.0 1 10/13/22 14:29 10/14/22 00:24 7440-66-6
2540D Total Suspended Solids Analytical Method:SM 254OD-2015
Pace Analytical Services-Asheville
Total Suspended Solids 2.9 mg/L 2.5 1 10/05/22 15:02
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 10/05/22 11:28 10/05/22 17:03
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
Date:10/14/2022 03:17 PM without the written consent of Pace Analytical Services,LLC. Page 6 of 15

Pace Analytical Services,LLC
® 9800 Kincey Ave. Suite 100
aceAnalytical Huntersville,NC 28078
www.pacelabs.com [phone]
QUALITY CONTROL DATA
Project: STORMWATER 3RD QUARTER
Pace Project No.: 92629171
QC Batch: 726933 Analysis Method: EPA 1664B
QC Batch Method: EPA 1664B Analysis Description: 1664 SGT HEM,TPH
Laboratory: Pace Analytical Services-Charlotte
Associated Lab Samples: 92629171001,92629171002
METHOD BLANK: 3796196 Matrix: Water
Associated Lab Samples: 92629171001,92629171002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Petroleum Hydrocarbons mg/L ND 5.0 10/11/22 03:15
LABORATORY CONTROL SAMPLE: 3796197
Spike LCS LCS %Rec
Parameter Units Conc. Result %Rec Limits Qualifiers
Total Petroleum Hydrocarbons mg/L 20 13.5 68 64-132
MATRIX SPIKE SAMPLE: 3796198
92629851001 Spike MS MS %Rec
Parameter Units Result Conc. Result %Rec Limits Qualifiers
Total Petroleum Hydrocarbons mg/L ND 19.2 18.8 88 64-132
SAMPLE DUPLICATE: 3796199
92629949001 Dup
Parameter Units Result Result RPD Qualifiers
Total Petroleum Hydrocarbons mg/L ND 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: 10/14/2022 03:17 PM without the written consent of Pace Analytical Services,LLC. Page 7 of 15

Pace Analytical Services,LLC
aceAnalytieal" 9800 Kinsey Ave. Suite100
Huntersvilte,NC 28078076
www.pacelabs.com [phone]
QUALITY CONTROL DATA
Project: STORMWATER 3RD QUARTER
Pace Project No.: 92629171
QC Batch: 730047 Analysis Method: EPA200.8
QC Batch Method: EPA 200.8 Analysis Description: 200.8 ATL
Laboratory: Pace Analytical Services-Peachtree Corners,GA
Associated Lab Samples: 92629171001,92629171002
METHOD BLANK: 3801457 Matrix: Water
Associated Lab Samples: 92629171001,92629171002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Copper ug/L ND 5.0 10/13/22 23:42
Lead ug/L ND 1.0 10/13/22 23:42
Zinc ug/L ND 10.0 10/13/22 23:42
LABORATORY CONTROL SAMPLE: 3801458
Spike LCS LCS %Rec
Parameter Units Cone. Result %Rec Limits Qualifiers
Copper ug/L 100 99.0 99 85-115
Lead ug/L 100 112 112 85-115
Zinc ug/L 100 101 101 85-115
MATRIX SPIKE&MATRIX SPIKE DUPLICATE: 3801459 3801460
MS MSD
92623749001 Spike Spike MS MSD MS MSD %Rec
Parameter Units Result Cone. Cone. Result Result %Rec %Rec Limits RPD Qual
Copper ug/L ND 100 100 104 105 100 101 70-130 1
Lead ug/L ND 100 100 109 110 109 110 70-130 1
Zinc ug/L 28.0 100 100 126 129 98 101 70-130 2
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: 10/14/2022 03:17 PM without the written consent of Pace Analytical Services,I.I.C. Page 8 of 15

Pace Analytical Services,LLC
aceAnalytical o 9800 Kinsey Ave. Suite100
Huntersville,NC 28078078
www.pacelabs.com [phone]
QUALITY CONTROL DATA
Project: STORMWATER 3RD QUARTER
Pace Project No.: 92629171
QC Batch: 728042 Analysis Method: SM 254OD-2015
QC Batch Method: SM 254OD-2015 Analysis Description: 2540D Total Suspended Solids
Laboratory: Pace Analytical Services-Asheville
Associated Lab Samples: 92629171001,92629171002
METHOD BLANK: 3791231 Matrix: Water
Associated Lab Samples: 92629171001,92629171002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Suspended Solids mg1L ND 2.5 10/05/22 14:59
LABORATORY CONTROL SAMPLE: 3791232
Spike LCS LCS %Rec
Parameter Units Conc. Result %Rec Limits Qualifiers
Total Suspended Solids mg/L 250 240 96 90-110
SAMPLE DUPLICATE: 3791383
92629044001 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 42.0 46.6 10
SAMPLE DUPLICATE: 3791384
92629100006 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 58.5 62.5 7
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:10/14/2022 03:17 PM without the written consent of Pace Analytical Services,LLC. Page 9 of 15

Pace Analytical Services,LLC
® 9800 Kincey Ave. Suite 100
aceAnalytical Huntersville,NC 28078
www.pacelabs,com [phone]
QUALITY CONTROL DATA
Project: STORMWATER 3RD QUARTER
Pace Project No.: 92629171
QC Batch: 727994 Analysis Method: SM 5220D-2011
QC Batch Method: SM 5220D-2011 Analysis Description: 5220D COD
Laboratory: Pace Analytical Services-Asheville
Associated Lab Samples: 92629171001,92629171002
METHOD BLANK: 3790986 Matrix: Water
Associated Lab Samples: 92629171001,92629171002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Chemical Oxygen Demand mg/L ND 25.0 10/05/22 16:57
LABORATORY CONTROL SAMPLE: 3790987
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: 3790988 3790989
MS MSD
92628745001 Spike Spike MS MSD MS MSD %Rec
Parameter Units Result Conc. Conc. Result Result %Rec %Rec Limits RPD Qual
Chemical Oxygen Demand mg/L ND 100 100 106 106 105 105 90-110 0
MATRIX SPIKE&MATRIX SPIKE DUPLICATE: 3790990 3790991
MS MSD
92628745002 Spike Spike MS MSD MS MSD %Rec
Parameter Units Result Conc. Conc. Result Result %Rec %Rec Limits RPD Qual
Chemical Oxygen Demand mg/L ND 100 100 120 120 120 120 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: 10/1412022 03:17 PM without the written consent of Pace Analytical Services,LLC, Page 10 of 15

Pace Analytical Services,LLC
aceAnalytical® 9800 KineyAve. Suite 100
Hvntersville,NC 28078076
www.pacelabs.com [phone]
QUALIFIERS
Project: STORMWATER 3RD QUARTER
Pace Project No.: 92629171
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 Chloroethyl vinyl ether.
A separate vial preserved to a pH of 4-5 is recommended in SW846 Chapter 4 for the analysis ofAcrolein and Acrylonitrile by EPA
Method 8260.
N-Nitrosodiphenyla mine decomposes and cannot be separated from Diphenyiamine 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
M1 Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample(LCS)recovery.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full,
Date: 10/14/2022 03:17 PM without the written consent of Pace Analytical Services,LLC. Page 11 of 15

Pace Analytical Services,LLC
aceAnalytical® 9800 KinceyAve. Suite 100
Huntersville,NC 28078078
www.pacelabs.com [phone]
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: STORMWATER 3RD QUARTER
Pace Project No.: 92629171
Analytical
Lab ID Sample ID QC Batch Method QC Batch Analytical Method Batch
92629171001 OUTFALL 1 B EPA 1664E 728933
92629171002 OUTFALL 2 EPA 1664B 728933
92629171001 OUTFALL 1 B EPA 200.8 730047 EPA 200.8 730142
92629171002 OUTFALL 2 EPA 200.8 730047 EPA 200.8 730142
92629171001 OUTFALL 1 B SM 2540D-2015 728042
92629171002 OUTFALL 2 SM 254OD-2015 728042
92629171001 OUTFALL 1 B SM 5220D-2011 727994 SM 5220D-2011 728141
92629171002 OUTFALL 2 SM 5220D-2011 727994 SM 5220D-2011 728141
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced,except in full.
Date: 10/14/2022 03:17 PM without the written consent of Pace Analytical Services,LLC. Page 12 of 15

`, vvrrir urc. r.rrv-rr�Ivr-nVry I-UUOJ vv'E aarnpie uonctition upon Keceipt
f ace
Effective Date: 051121202205/12/2022
Laboratory receiving samples:
Asheville❑ Eden❑ Greenwood ❑ Huntersville Raleigh❑ Mechanicsville[] Atlantan Kernersvillm-1
Client Name: I 4MEMO o r I Project fl: .
4A5�� ,4 r e P ? -'
Courier: ❑Fed Ex ❑UPS ❑LISPS []client
❑Commercial ❑Pace ❑Other:
92629171
Custody Seal Present? ❑Yes bNo Seals Intact? ❑Yes dNo /
Date/Initials Person Examining Contents-'.•' '
I
r
Packing Material: ❑Bubble Wrap ❑Bubble Bags []None ❑ Other Biological TissuefFrozen?
Thermo me er: Dyes ❑No ❑N/A
1IR Gun lD: V �t
Type of-Ice: ❑Wet ❑blue ❑tdane
Correction Factor:
Cooler Temp: i Add/Subtract 'C _.�
( ) Temp should be above freezing to 6'C
❑Sams les out of temp criteria.Samples on ice,cooling process
Cooler Temp Corrected(jC): ' ; leas begun
USDA Regulated Soil(ff N/A,water sample)
Did samples originate in a quarantine zone within the United States:CA,NY,or SC Did samples originate from a roreign source(internationally,
(check maps)?❑yes ❑ND including Hawaii and Puerto Rico)?❑Yes ❑No
Comments/Discrepancy:
Chain of Custody Present? Elf cs ❑No ❑N/A 11
Samples Arrived within Hold Time? ❑Yes ❑No ❑N/A 2.
Short Hold Time Analysis(<72 hr.)? Yes dNo ❑N/A 3.
Rush Turn Around Time Requested? dyes ❑No ❑N/A 4.
i
Sufficient Volume? Yes C]No ❑N/A 5.
Correct Containers Used? dYes ❑No []N/A 6.
-Pace Containers Used? EjYes []No ❑N/A
Containers Intact? CQYes ONO ❑N/A 7.
Dissolved analysis:Samples Field Filtered? ❑Yes ONO QN/A 8,
Sample labels Match COC? []Yes ❑No ❑NJA 9.
-Includes Date/Time/ID/Analysis Matrix: `
Headspace in VOA Vials(>5.6mm)? Oyes ❑No QN/A 10.
Trip Blank Present? ❑yes ❑No []N/A 11.
Trip Blank Custody Seals Present? ❑Yes ❑No JN/A
C4MMENTSJSAMPLE DISCREPANCY Field Data Required? ❑Yes []No
CLIENT NOTIFICATION/RESOLUTION Lot ID of split containers:
Person contacted: Date/Time:
Project Manager SCURF Review: _ Date:
Promr.t rV7ao".Pr CiL r,"";......
- u49 CL:
Qualtrax ID:69614 Page 1 of 2 Page 13 of 15

i ace
Effective Date: 05/12/20220S/12/2022
11 1
*Check mark top half of box if pH and/or dechlorination is verified and Project PM: TIFF Due Date: 10/11/22
within the acceptance range for preservation samples. CLIEN'r: 92-Rg i i i tV F
Exceptions:VOA,Coliform,TOC,Oil and Grease,DRO/8015{water)DOC,Wig
**Bottom half of box is to list number of bottles
***Check all unpreserved Nitrates for chlorine
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pH Adjustment Log for Preserved Samples
Sample ID Type of Preservative pH upon receipt Date preservation adjusted Time preservation Amount of Preservative Lot N
adjusted added
„u.�. -I IICI Icve, Meru I d uisci ePducy dIiecung rvonn Larolma cornPuancc samples,a COPY Ofthis torn,will tie sent to the North Carolina DEN Certification Office(i.e.
Out of hold,incorrect preservative,out of temp,incorrect containers.
Qualtrax ID:69614 Page 2 of 2 Page 14 of 15

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n 0
♦� SAMPLE TYFE (G-GRAB C-CONIP)
N o �
9
fA
D m & w
m rn m a
Q
w
X O n
z
m 0 o
m m =
a
e � " rn n n
y -� z w E
N Z
mv
A b SAMPLE TEMP AT COLLECTION m in I
° n
\- pOF CONTAINERS � a ; 90 a � " � CL
® m 9 , 3 . m � e
Q Unpreservad a. w r o N Cn
\ �O
H2$04 z u 0 ro r O
� m �
HNO3 0 a rc
^� 3 D
HCI m 5
NaOH l a O D
S a C
OA Na2S203 � n K Di
m,
hlelhanal v, Z
Other $ D
Analyses Test YIN d � � m
9
N F y 2 F$$ w w tb
Metals CU O n a N
a COO w
� o
c Cr 0
o C
0 CL
44T
N �
�\ N
4 �
w
w .
TENT in C
Residual Ch'Cnne(Y!N) y
Received on rL
8
Ice Z gr
(YIN)
0
Jamples
Intact
(Y!N) LH- I L� 1 1111 U
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