WQ0039473_Monitoring - 07-2022_20220909

FORM: NDAR-1 10-13
NON-DISCHARG PPLICATION REPORT (NDAR-1)
Page
Permit No.: W00039473
Facility Name: Atkinson Milling Company
County: Johnston
Month: ui
Year: XI }
Field Name:
Z1
Field Name:
Z2
Field Name:
Z3
Feld 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?
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14
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16
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20
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23
24
25
26
27
28
29
30
31
Monthly Loading:
7
12 Month Floating Total (in):
3j
M

FORM: NDAR-1 10-13 NON -DISCHARGE APPLICATION REPORT (NDAR-1)
Did the application rates exceed the limits in Attachment B of your permit? No
Page of
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
—C-1c1 f,l an Gttarh aririifinnal Sheets if necessary.
Ago g mo't t>"ham--
/ t"', r k_--ruc,k- rra5 S fa l r.� _ K2 P� Nu kbo�,,K Z7
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P° � ec.�.
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 O anged si a the previous NDAR-1? No
Phone Num 919-631-7572 Permit Exp.: 4/30/23
^
/
07
Signature Date
Signature Date
By this signature, I certify that this report is accurrale and complete to the best of my knowledge.
I certify, under penally 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
Permit No.: VV00039473
Facility Name: Atkinson Milling Company
County: Johnston
Month: J
Year:
PPI:
Flow Measuring Point: Effluent
Parameter Monitoring Point: Effluent
Parameter Code —►
50050
a
O
c
O
P
O
All
�h
24-hr
hrs
GPD
2
�c
41;7
i.7
i t
Ott
�C�J
3
4
5
6
7
—
8
9
10
11
—
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
—
31
.�
Average:
—
Daily Maximum:
—
Daily Minimum:
—
Sampling Type:
—
Monthly Avg. Limit:
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.
5 ��
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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 OR c nged since the previous ND R? No Phone Numb 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 property 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

*MICROBACOk
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2H0154
Project Description
Wastewater Sample
For:
Andrew Wheeler
Atkinson Milling Company
95 Atkinson Mill RD
Selma, NC 27576
- 1
Administration
Brittany Smith
Monday, August 22, 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 283061910.864.1920 p I www.microbac.com
Page 1 of 9

*MICROBACk
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2H0154
Atkinson Milling Company
Andrew Wheeler
95 Atkinson Mill RD
Selma, NC 27576
Sample Summary Report
Sample Name Laboratory ID Client Matrix
Spray Tank, Grab K21-10154-01 Aqueous
Project Name: Wastewater Sample
Project / PO Number: N/A
Received: 08/08/2022
Reported: 08/22/2022
Sample Type Sample Begin Sample Taken Lab Received
Grab 08/08/22 09:30 08/08/22 11:30
Page 2 of 9

*MICROBAC`
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2H0154
Analytical Testing Parameters
Client Sample ID: Spray Tank, Grab
Sample Matrix: Aqueous Collected By: Andrew Wheeler
Lab Sample ID: K21-10154-01 Collection Date: 08/08/2022 9:30 i
Analyses Performed by: Microbac Laboratories, Inc. - Fayetteville
Microbiology Result RL Units DF Note Prepared Analyzed Analyst
SM 9222 D-2015
Fecal coliforms > 60,000 per 100 1.0 per 100ml- 1 08/08/22 1554 08/09/22 1452 WPR
mL
Inorganics Total
Result
RL
Units
DF
Note
Aqueous Ammonia Distillation/SM 4500-NH3
G-2011
Ammonia as N
22.1
0.200
mg/L
1
Calculation
Total Nitrogen
41.7
5.33
mg/L
5
EPA 351.2, Rv. 2 (1993)
Total Kjeldahl Nitrogen (TKN)
41.7
5.33
mg/L
5
SM 2540 D-2015
Total Suspended Solids (TSS)
129
33.3
mg/L
13
SM 4500-H+ B-2011
pH (at 25°C)
5.9
1.0
S.U.
1
H
SM 4500-P F-2011
Method Notes: Al2
Phosphorus as P
41
5.0
mg/L
25
SM 5210 B-2016
Biochemical Oxygen Demand (BOD5)
2600
2.00
mg/L
1
Analyses Performed by: Microbac Laboratories,
Inc.,
Maryville
Inorganics Total
Result
RL
Units
DF
Note
EPA 300.0, Rv. 2.1 (1993)
Nitrate as N
<0.200
0.200
mg/L
1
Nitrite as N
<0.200
0.200
mg/L
1
M1
Prepared
Analyzed
Analyst
08/16/22 2012
KNL
08/10/22 1645
KNL
08/10/22 1645
KNL
08/10/22 1550
BNS
08/12/22 0832
08/15/22 1031
WPR
08/12/22 1719
08/12/22 1719
KNL
08/08/22 1222
08/13/22 1410
WPR
Prepared
Analyzed
Analyst
08/09/22 1318
08/09/22 1318
TXN
08/09/22 1318
08/09/22 1318
TXN
Microbac Laboratories, Inc.
2592 Hope Mills Rd I Fayetteville, NC 28306 1910.864.1920 p I www.microbac.com Page 3 of 9

�VMICROBAC '
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2H0154
Batch Log Summary
Method
Batch Laboratory I
Client / Rn���r•�a in
EPA 300.0, Rv. 2.1 (1993)
2233108 2233108-BLK1
2233108-BS1
K2H0154-01
Spray Tank, Grab
2233108-MS1
K2H0154-01
2233108-MSD1
K2H0154-01
__ Method ___
Batch Laboratory ID
Client /Source ID
SM 5210 B-2016
KH2O508 K2H0154-01
___
Spray Tank, Grab
KH2O508-BS1
KH2O508-DUP1
K2H0005-01
KH2O508-BLK1
Method
Batch Laboratory ID
Client / Source ID
SM 9222 D-2015
KH2O802 K2H0154-01
Spray Tank, Grab
KH2O802-DUP1
K2H0154-01
KH2O802-BLK1
KH2O802-BLK2
KH2O802-BS1
Method Batch Laboratory ID
Client / Source ID
EPA 351.2, Rv. 2 (1993) KH2O811 KH2O811-BS1
_
KH2O811-MS2
K2H0029-01
KH2O811-MSD1
K2H0013-01
KH2O811-MSD2
K2H0029-01
K2H0154-01
Spray Tank, Grab
KH20811-MS 1
K9Hnn l A-n l
_ Method Bath Laboratory ID Client / So irrn in
SM 2540 D-2015 KH2O822 KH2O822-BLK1
KH2O822-DUP1 K2H0034-02
KH2O822-BS1
K2H0154-01 Snrav Tank r_r.h
Method
Batch
Laboratory ID
Client /Source ID
SM 4500-H+ B-2011
KH21112
K2H0154-01
_ _
Spray Tank, Grab -
KH21112-DUP1
K2H0003-02
Method
Batch
Laboratory ID
Client /Source ID
SM 4500-P F-2011
KH21113
KH21113-BSI
KH21113-MS2
K2F0431-01
KH21113-MSD2
K2F0431-01
Microbac Laboratories, Inc.
2592 Hope Mills Rd I Fayetteville, NC 283061910.864.1920 p I www.mlcrobac.com Page 4 of 9

�MICROBACR
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2H0154
SM 4500-P F-2011 KH21113 K21-10154-01
Spray Tank, Grab
KH21113-M S 1
K21-10154-01
KH21113-MSD1
K21-10154-01
hod Batch Laboratgry1D
Client/ QUEceID
_
SM 4500-NH3 G-2011 KH21603 KH21603-BS1
KH21603-DUP1
K21-10030-01
KH21603-MS1
K2H0030-01
K2H0154-01
Spray Tank, Grab
KH21603-BLK1
Batch Quality Control Summary: Microbac Laboratories, Inc. - Fayetteville
Spike Source %REC RPD
Microbiology Result RL Units Level Result %REC Limits RPD Limit Notes
Batch KH2O802 - Wet Chem Aqueous - SM 9222 D-2015
Blank (KH2O802-BLK1)
Fecal coliforms <1.0 1.0
Blank (KH2O802-BLK2)
Fecal coliforms <1.0 1.0
LCS (KH2O802-BS1)
Fecal coliforms 7900 1.0
Duplicate (KH2O802-DUP1)
Fecal coliforms
Source: K2H0154-01
<1.0 1.0
Inorganics Total Result
Batch KH2O508 - Wet Chem Aqueous - SM 5210 B-2016
Blank (KH2O508-BLK1)
Biochemical Oxygen Demand <2.00
(BOD5)
LCS (KH2O508-BS7)
Biochemical Oxygen Demand 194
(BOD5)
Prepared: 08/08/2022 Analyzed: 08/09/2022
per
100mL
Prepared: 08/08/2022 Analyzed:08/09/2022
per
100ml-
Prepared: 08/08/2022 Analyzed: 08/09/2022
per 0-200
100ml-
Prepared:08/08/2022 Analyzed:08/09/2022
per 300 per 1C
100ml-
10
Spike Source %REC RPD
RL Units Level Result %REC Limits RPD Limit Notes
Prepared: 08/08/2022 Analyzed: 08/13/2022
2.00 mg/L -
Duplicate (KH2O508-DUP1) Source: K2H0005-01
Biochemical Oxygen Demand 943 2.00
(BOD5)
Batch KH2O811 - Wet Chem Aqueous - EPA 351.2, Rv. 2 (1993)
Prepared: 08/08/2022 Analyzed: 08/13/2022
mg/L 198 98 .59596-115.4
Prepared: 08/08/2022 Analyzed: 08/13/2022
mg/L 950 0.8 30
LCS (KH2O811-BSI) Prepared &Analyzed: 08110/2022
Total Kjeldahl Nitrogen (TKN) 5.17 1.00 mg/L 5.00 103 90-110
Matrix Spike (KH2O811-MSI) Source: K21-10013-01 Prepared & Analyzed: 08/10/2022
Total Kjeldahl Nitrogen (TKN) 9.92 5.33 mg/L 5.00 3.40 130 90-110
Microbac Laboratories, Inc.
2592 Hope Mills Rd I Fayetteville, NC 283061 910.864.1920 p I www.micro',oac.com
Page 5 of 9

�MICROBAC`a
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2H0154
Spike Source %REC RPD
Inorganics Total Result RL Units Level Result %REC Limits RPD Limit Notes
Batch KH2O811 - Wet Chem Aqueous - EPA 351.2, Rv. 2 (1993)
Matrix Spike (KH2O811-MS2)
Source: K21-10029-01
Prepared & Analyzed: 08/10/2022
Total Kjeldahl Nitrogen (TKN)
9.37 1.00
mg/L 5.00 3.44 119 90-110
Matrix Spike Dup (KH2O811-MSD1)
Source: K21-10013-01
Prepared &Analyzed: 08/10/2022
Total Kjeldahl Nitrogen (TKN)
6.25 1.00
mg/L 5.00 3.40 57 90-110 45 10
Matrix Spike Dup (KH2O811-MSD2)
Source: K2H0029-01
Prepared & Ana_ lyzed: 08/10/2022
Total Kjeldahl Nitrogen (TKN)
9.28 1.00
mg/L 5.00 3.44 117 90-110 0.9 10
Batch KH2O822 - Wet Chem Aqueous - SM 2540 D-2015
PBW01 (KH2O822-BLK1)
Prepared &Analyzed: 08/10/2022
Total Suspended Solids (TSS)
<83.3 83.3
mg/L
LCSW01 (KH2O822-BSI)
Prepared &Analyzed: 08/10/2022
Total Suspended Solids (TSS)
97.7 2.50
mg/L 99.4 98 95-105
Reactor#2D (KH2O822-DUP1)
Source: K21-10034-02
Prepared &Analyzed: 08/10/2022
Total Suspended Solids (TSS)
6030 833
mg/L 5700 6 10
Batch KH21112 - Wet Chem Aqueous - SM 4500-H+ B-2011
TPE, GrabD (KH21112-DUP1)
Source: K21-10003-02
Prepared: 08/12/2022 Analyzed: 08/15/2022
pH (at 25°C)
7.0 1.0
S.U. 7.0 0.1 10
Batch KH21113 - Wet Chem Aqueous - SM 4500-P F-2011
LCSS01 (KH21113-BSI)
Prepared &Analyzed: 08/12/2022
Phosphorus as P
2.0
0.20
mg/L 2.0 101
Spray Tank, GrabS (KH21113-MS1)
Source: K21-10154-01
Prepared &Analyzed: 08/12/2022
Phosphorus as P
44
5.0
mg/L 2.0 41 102
Outfall #6, grabS (KH21113-MS2)
Source: K21`0431-01
Prepared &Analyzed: 08/12/2022
Phosphorus as P
8.6
1.0
mg/L 2.0 6.4 109
Matrix Spike Dup (KH21113-MSD1)
Source: F2H0154-01
Prepared &Analyzed: 08/12/2022
Phosphorus as P
45
5.0
mg/L 2.0 41 180
Matrix Spike Dup (KH21113-MSD2)
Source: K2F0431-01
Prepare_ d &Analyzed: 08/12/2022
Phosphorus as P
8.6
1.0
mg/L 2.0 6.4 108
Batch KH21603 - NH3PR W - SM 4500-NH3 G-2011
Blank (KH21603-BLK1)
Ammonia as N
LCS (KH21603-BS1)
Ammonia as N
Duplicate (KH21603-DUP1)
Ammonia as N
Matrix Spike (KH21603-MS1)
Ammonia as N
90-110
90-110
90-110
90-110 4 200
90-110 0.3 200
- Prepared: 08/16/2022 Analyzed: 08/17/20.22
<0.200 0.200 mg/L
Prepared & Analyzed: 08/16/2022
0.965 0.200 mg/L 1.00 96 90-110
Source: K2H0030-01 Prepared &Ana_lyzed: 08/16/2022
0.543 0.200 mg/L 0.529 3 10
Source: K21-10030-01 Prepared &Analyzed: 08/16/2022
1.41 0.200 mg/L 1.00 0.529 88 80-120
Microbac Laboratories, Inc.
2592 Hope Mills Rd I Fayetteville, NC 28306 1910.864.1920 p I www.microbac.com Page 6 of 9

*MICROBACR
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2H0154
Batch Quality Control Summary: Microbac Laboratories, Inc., Maryville
Inorganics Total Result RL
Batch 2233108 - WetChem IC - EPA 300.0, Rv. 2.1 (1993)
Spike Source
Units Level Result %REC
%REC
Limits RPD
RPD
Limit
Notes
Blank (2233108-BLK1)
Prepared &Analyzed: 08/09/2022
Nitrate as N
<0.100
0.100
mg/L
69
Nitrite as N
<0.100
0.100
mg/L
89
LCS (2233108-BSI)
Prepared &Analyzed: 08/09/2022
Nitrate as N
2.20
0.100
mg/L 2.26 97.2
90-110
Nitrite as N
3.03
0.100
mg/L 3.04 99.6
90-110
Matrix Spike (2233108-MS1)
Source: K2H0154-01
Prepared &Analyzed: 08/09/2022
Nitrate as N
7.91
0.235
mg/L 7.98 0.104 97.9
90-110
Nitrite as N
12.5
0.235
mg/L 10.7 ND 116
90-110
M1
Matrix Spike Dup (2233108-MSD1)
Source: K2H0154-01
Prepared &Analyzed: 08/09/2022
Nitrate as N
7.95
0.235
mg/L 7.98 0.104 98.4
90-110 0.504
20
Nitrite as N
12.6
0.235
mg/L 10.7 ND 117
90-110 0,938
20
M1
Definitions
Al2: MS/MSD fail recovery, but the LCS passes criteria.
B9: Target analyte is detected in the method blank at or
above
the method detection limit but below the method reporting
limit.
H: Analyte was prepared and/or analyzed outside of the analytical method holding time
M1: Matrix spike recovery is outside of acceptance limits, biased high.
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: 5.5°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
Microbac Laboratories, Inc.
2592 Hope Mills Rd I Fayetteville; NC 28306 1910.864.1920 p I www.microbac.com Page 7 of g

�VMICROBAC`°
Microbac Laboratories, Inc. - Fayetteville
CERTIFICATE OF ANALYSIS
K2H0154
Project Requested Certification(s)
Microbac Laboratories, Inc. - Fayetteville
11 North Carolina DENR NPDES
Microbac Laboratories, Inc., Maryville
678 NC Dept. of Environmental Quality
Report Comments
Reviewed and Approved By:
Samples were received in proper condition and the reported results conform to
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 <httas://www.mkrobac.com/standard-terms-conditions>. Reported: 08/22/2022 21:05
Microbac Laboratories, Inc.
2592 Hope Mills Rd I r�-;yetteville, NC 28306 1910.864.1920 p I www.microbacoc, to Page 8 of 9

-- II*I KII2IIIHII QII1I 5II 4I I*
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CHAIN OF G:Si
25324ope')F:s Frd. Number II III 0
0)OhlCn0DAh!/ Fayetteville, NC 28306 Inslrcxarnns orba.
_ -._. _ _ _ ......._... .... __ . _..
...— ............... ...-----•.------ -- .. TO BE COMPLETED
^-----_--^--•-_-__•- ' � J �I ti -� `'�lr.�f �;rinvoice Address Turnaround Time �
Lab Report Address 11t�s r�—� 64011, . t J Koutrne (s to i nusrness uay" Temp. Upon Receipt f=�) 3',� h� "' ro
Client Name: . L1S15r�yQ� 1��1.F1► Client Name: _._..—.__... ...... .....----
[ ]RUSH'" (notify lab) Holding Time
D r�ir�l ft-K A) Address: —. _...—__...___—_-.----- sa m les Received on ice? Q No N/A
Address: 1 �_%�r , �--.-. --- p
City, state, Zip ^- (neecicd by)
City, State, Zir ,6VG.• L s — _ _ -- -' Custody Seals intact' !es No N/A
�p1- - f" Contact: — Report Type r
Contact: /-rJ1 ftr`<'itir [s��� --•--'_'-------..._"_
Telephone N Results Only ( ]Level 1 ( ] Level Z [ J Levef3 ( ] Level 4 ( ) EDD
Telephone No. G% �r u ! '7:a 7 p Q c - ___.
vi�,� tc�i ' 1(L++�• c: �c4�r;l .!'•+N Send invoice vi l I Mail [ I Fax [�] a -mail
Send Report via [ ] Mail l 1 Fax fvr1 -r'nail GA_-,_ _—
r Compliance Monitoring? [ ff Yes [ ] No [ ]Agency/Progran
r j f
Project: 1��'� _ Location: LL/V�' a\. '� fZv �__.. PO No.: —..- Phone_ N
r — t 1t
�i - �` ;ampler A
�� \ 'r( L`" Sampler Signature: ......�^ Pi... ��........�............._....
sampled by (PRINT):_./.gn.. Act; �......:................................................. .......
Matrix Types:5oil/Solid (S). Sludge. Oil, Wipe, Drinking Water (01N), Groundwater (GW), Surface Water (SW). Waste Water (WW), Other (specify)
** Preservative Types:(1) HNO3, (2) i-1Z504, (3) HCI, (4) NaOH, (5) Zinc Acetal:e, (fi) Methanol, (?) Sodium Bisulfate, (8) Sodium'('luosulfafe. (9) Hexane, (U) lJn[Jresr_rved
REQUESTED ANALYSIS
Possible Hazard Identific [ I Hazardous
_............................................................ _......
Comments
(
I
] Npn-Hazardous [ ]Radioactive
f� .............
R]I ngurshed By (Signature)
Re li sh D I ure)
......................
Re inquished By ignaturr )
Date/Time
Date/Time
[ ] Dispose as appropriate
Received By (signature)
R iv y ( -gnatPie
R eived By (stanat
Additional Afotes
Date/Tirne
Qg�INe
2�......l.l.'Q_
Date/Time
61 *1 gj0?1_L