NC0027197_Renewal (Application)_20230308

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NORTH CAROLINA
Post Office Box 207 Shelby, NC 28151-0207 ,
March 2, 2023
NCDEQ Division of Water Resources
NPDES Compliance and Expedited Permitting
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: City of Shelby Water Treatment Plant
NPDES NCO027197 Renewal (Form 1 and Form 2C)
Dear NPDES Unit:
RECEIVED"
MAR 0 S 2023
NCDEQ/DWR/NPDES
Enclosed you will find an information packet containing Form 1 and Form 2C for the
renewal of the City of Shelby's Water Treatment Plant (NPDES NC 0027197).
Please contact me, Brian Wilson at 704-484-6840 or [e-mail] with
questions or concerns.
Sincerely
Brian Wilson
Water Resources Operations Manager
Cc Brad Greene, Plant Operations Superintendent
Billy Wilkie, City of Shelby WTP ORC
Certified Mail
7012 2920 0001 9630 7160

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110022324607
NCO027197
City of Shelby Water Treatment
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
1
18rEPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
SECTION•NPDES
1.1 Applicants Not
Required to Submit Form 1
1.1.1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
treating domestic sewage?
If yes, STOP. Do NOT complete No
If yes, STOP. Do NOT No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
.=
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
operation or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
IL
production facility?
currently discharging process wastewater?
oYes
-+ Complete Form 1 No
Yes 4 Complete Form ❑ No
a
and Form 2B.
1 and Form 2C.
z
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
A
C
mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
—
commenced to discharge?
discharges only nonprocess wastewater?
g
❑ Yes 4 Complete Form 1 ❑✓ No
Yes 4 Complete Form No
and Form 2D.
1 and Form 2E.
M
1.2.5
Is the facility a new or existing facility whose
discharge is composed entirely of stormwater
a
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
❑ Yes 4 Complete Form 1 n No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
(b)(15).
SECTIONDD-
• • i
2.1
Facility Name
City of Shelby Water Treatment Plant
C
2.2
EPA Identification Number
w
A
110022324607
v
0
2.3
Facility Contact
d
Name (first and last)
Title
Phone number
�
Billy Wilkie
ORC
[phone]
Q
c
Email address
[e-mail]
d
2.4
Facility Mailing Address
zStreet
or P.O. box
PO Box 207
City or town
State
ZIP code
Shelby
North Carolina
28151
EPA Form 3510-1 (revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110022324607
NCO027197
City of Shelby Water Treatment
OMB No. 2040-0004
"i
2.5
Facility Location
a w
Street, route number, or other specific identifier
Q o
0
801 West Grover Street
rn
C c
County name
County code (if known)
cc 4
Cleveland
023
0
E
City or town
State ZIP code
z
Shelby
North Carolina 28150
SECTION•D
1
3.1
SIC Code(s)
Description (optional)
4941
Water Supply
w
m
0
0
U
N
U
Z
-o
3.2
NAICS Code(s)
Description (optional)
A
221310
Water Supply and Irrigation Systems
U
Cn
4.1
Name of 0 erator
Billy Wilkie
`0
4.2
Is the name you listed in Item 4.1 also the owner?
oEl
Yes 0No
0
7Z
4.3
Operator Status
❑ Public —federal Public —state ❑ Other public (specify)
a
El Private El Other
0
(specify)
4.4
Phone Number of Operator
[phone]
4.5
Operator Address
0
Street or P.O. Box
R
PO Box 207
w
City or town
State
ZIP code
o 0
Shelby
North Carolina
28151
is
0
CL
Email address of operator
0
[e-mail]
SECTION•
•1
Is the facility located on Indian Land?
o
5.1
0
❑ Yes ❑✓ No
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110022324607 NCO027197 City of Shelby Water Treatment OMB No. 2040-0004
ENVIRONMENTALI
6.1 Existing Environmental Permits (check all that apply and print or type the corresponding permit number for each)
❑ NPDES (discharges to surface
❑ RCRA (hazardous wastes)
❑ UIC (underground injection of
oY
water)
fluids)
2
NCO027197
w a
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
❑ NESHAPs (CAA)
rn
x
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section 404)
❑ Other (specify)
w
7.1 Have you attached a topographic map containing all required information to this application? (See instructions for
specific requirements.)
ID Yes ❑ No ❑ CAFO—Not Applicable (See requirements in Form 2B.)
8.1 1Describe the nature of your business.
The City of Shelby WTP recieves water from the First Broad River, runs the water through a treatment process which
includes sedimentation, flocculation and filtration and provides potable water for the City of Shelby and surrounding
co
U) area. Waste water and sediments containing possible pollutants are sent to one of two recieving ponds where time
U) is allowed for settling and testing before being discharged to an unnamed tributary of the First Brosd River. Solids
.N g g g g Y
m that are settled out are removed periodically and land applied as a class A producted on local farm land, via a
0 1 1 sub -contractor
9.1 Does your facility use cooling water?
d ❑ Yes ❑✓ No 4 SKIP to Item 10.1.
9.2 Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
co 40 CFR 125, Subparts I and J may have additional application requirements at 40 CFR 122.21(r). Consult with your
•o Y NPDES permitting authority to determine what specific information needs to be submitted and when.)
U
10.1 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
co apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
when.)
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
U
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
❑✓ Not applicable
EPA Form 3510-1 (revised 3-19) Page 3

EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03/05/19
110022324607
NCO027197
City of Shelby Water Treatment OMB No. 2040-0004
SECTION•
1
11.1
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2
❑✓ Section 1: Activities Requiring an NPDES Permit
❑ w/ attachments
0 Section 2: Name, Mailing Address, and Location
❑ w/ attachments
❑✓ Section 3: SIC Codes
❑ w/ attachments
❑✓ Section 4: Operator Information
❑ w/ attachments
❑✓ Section 5: Indian Land
❑ w/ attachments
..
❑✓ Section 6: Existing Environmental Permits
0 w/ attachments
c
d
E
❑✓ Section 7: Map
w/ topographic
❑✓ ❑ w/ additional attachments
ma
in
c
Section 8: Nature of Business
Elw/ attachments
❑✓ Section 9: Cooling Water Intake Structures
❑ w/ attachments
r-
�'
-o
❑� Section 10: Variance Requests
❑ w/ attachments
c
Section 11: Checklist and Certification Statement
❑ w/ attachments
_)
Y
d
11.2
Certification Statement
s
c.�
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 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. 1 am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Brian Wilson
Water Resources Operations Manager
Signature
Date signed
03/02/2023
EPA Form 3510-1 (revised 3-19) Page 4

First Broad River Intake
5.3 MGD
Schematic of Water Flow
City of Shelby Water
Water Treatment Chemicals
and Process Water
0.055 MGD
Storage Reservoirs Flocculation and
Sedimentation
5.3MGD 5.3 MGD
Stormwater
0.004 MGD
Treatment Plant
Filter Backwash Tank Distribution System
0.09MGD 0.09 MGD
Backwash and Reject Water
Treatment Ponds
0.145 MGD
LI
Outfall 001 Un-Named Tributary of
the First Broad River
0.145 MGD
Finish Water/Clear Wells
5.3 MGD
Distribution System
5.3 MGD

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110022324607 NCO027197 City of Shelby Water Treatment OMB No. 2040-0004
Form U.S. Environmental Protection Agency
2C \—/EPA Application for NPDES Permit to Discharge Wastewater
NPDES EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS
SECTIONOUTFALL LOCATION1
1.1 Provide information on each of the facility's outfalls in the table belowOutfall
Number Receiving Water Name Latitude Longitude
001 Un-Named Tributary of the 1 35' 18' 67 N 81' 33' 36' W
O
SECTIOND' 1
o, 2.1 Have you attached a line drawing to this application that shows the water flow through your facility with a water
3 balance? (See instructions for drawing requirements. See Exhibit 2C-1 at end of instructions for example.)
J c ❑✓ Yes ❑ No
SECTION• AND 1
3.1 For each outfall identified under Item 1.1, provide average flow and treatment information. Add additional sheets if
necessary.
"Outfall Number" 001
Operations
Operation Average Flow
Sedimentation 0.00046 mgd
c
E Flocculation 0.00046 mgd
is
m
r= Filter Backwash Dechlorination Process Water 0.002 mgd
r
c
Backwash, Process and Reject Water Flow 0.145 mgd
3
0 Treatment Units
U-
Description Code from Final Disposal of Solid or
(include size, flow rate through each treatment unit, Table 2C-1 Liquid Wastes Other Than
a retention time, etc. _ by Discharge
lately 171,333 Gallons, Average Daily Flow of 5.3 MG, appro 1-G Class A Land Application
f 1,649,499 Gallons, Average Daily Flow 5.3 MG, approximat 1-U Class A Land Application
Iter, Maximum Flow rate of 1,440 GPM, Average Daily Flow ( 1-Q Class A Land Application
tanks, one metering pump set a feed rate of 105 mL per mi 2-E Class A Land Application
EPA Form 3510-2C (Revised 3-19) Page 1

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110022324607
NCO027197
City of Shelby Water Treatment
OMB No. 2040-0004
3.1
"Outfall Number"
cont.
Operations Contributing to Flow
Operation Average Flow
Stormwater/Runoff
0.004 mgd
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
retention time, etc.)
by Dischar e
"0
d
c
c
0
U
c
a>
E
A
m
H
"Outfall Number"
cc
o
Operations Contributing to Flow
Operation Average Flow
LL
o,
mgd
�a
d
¢'
mgd
mgd
mgd
Treatment
Description
Units
Code from
Final Disposal of Solid or
(include size, flow rate through each treatment unit,
Table 2C-1
Liquid Wastes Other Than
retention time, etc.)
by Discharge
3.2
Are you applying for an NPDES permit to operate a privately owned treatment works?
d La❑
Yes ✓❑ No 4 SKIP to Section 4.
N3.3
Have you attached a list that identifies each user of the treatment works?
❑ Yes ❑ No
EPA Form 3510-2C (Revised 3-19) Page 2

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110022324607 NCO027197 City of Shelby Water Treatment OMB No. 2040-0004
SECTION• 1
4.1 Except for storm runoff, leaks, or spills, are any discharges described in Sections 1 and 3 intermittent or seasonal?
❑� Yes ❑ No 4 SKIP to Section 5.
4.2
Provide information
on intermittent or seasonal flows for each applicable outfall.
Attach additional pages, if n cessary.
Freq
uency
Flow
Rate
Outfall
Operation
Duration
Average
Average
Long -Term
Maximum
Number
(list)
Da sMeek
MonthsNear
Average
Dail
De -Chlorination
7 days/week
12 months/year
3.00032 mgd
3.00032 mgd
15.16 days
001
Filter Backwashing
7 days/week
12 months/year
0.080 mgd
0.273 mgd
365 days
LL
Flocculator Washing
0.23 days/week
0.058 months/year
0.043 mgd
0.086 mgd
12 days
Sed. Basin Washing
0.23 days/week
0.058 months/year
0.420 mgd
0.825 mgd
12 days
c
days/week
months/year
mgd
mgd
days
001
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week
months/year
mgd
mgd
days
days/week months/year mgd mgd days
SECTION"•D
• I
5.1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your facility?
❑ Yes [D No 4 SKIP to Section 6.
h
5.2
Provide the following information on applicable ELGs.
ELG Category
ELG Subcategory
Regulatory Citation
w
a�
•a
c�
.n
c.
a
5.3
Are any of the applicable ELGs expressed in terms of production (or other measure of operation)?
❑ Yes ❑ No 4 SKIP to Section 6.
0
%
5.4
Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
J
Outfall
Operation, Product, or Material
Quantity per Day
Unit of
Number
Measure
d
cc
m
0
u
0
0
n.
EPA Form 3510-2C (Revised 3-19) Page 3

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110022324607 NCO027197 City of Shelby Water Treatment OMB No. 2040-0004
SECTION'• 1
6.1 Are you presently required by any federal, state, or local authority to meet an implementation schedule for constructing,
upgrading, or operating wastewater treatment equipment or practices or any other environmental programs that could
affect the discharges described in this application?
❑ Yes ❑✓ No 4 SKIP to Item 6.3.
6.2
Briefly identify each applicable project in the table below.
Affected
Final Compliance Dates
E
Brief Identification and Description of
Outfalls
Source(s) of
0)
o
Project
(list outfall
Discharge
Required
Projected
Q
number
E
ca
d
'O
�
I
rn
Q
6.3
Have you attached sheets describing any additional water pollution control programs (or other environmental projects
that may affect your discharges) that you now have underway or planned? (optional item)
❑ Yes ❑ No ✓❑ Not applicable
SECTIONr
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
complete. Not all applicants need to complete each table.
Table A. Conventional and Non -Conventional Pollutants
7.1
Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A pollutants for any of
your outfalls?
❑ Yes ❑✓ No 4 SKIP to Item 7.3.
7.2
If yes, indicate the applicable outfalls below. Attach waiver request and other required information to the application.
Outfall Number Outfall Number Outfall Number
7.3
Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
N
requested and attached the results to this application package?
0 Yes ❑ No; a waiver has been requested from my NPDES
ca
permitting authority for all pollutants at all outfalls.
Table B.
Toxic Metals, Cyanide, Total Phenols, and Organic Toxic Pollutants
Y
7.4
Do any of the facility's processes that contribute wastewater fall into one or more of the primary industry categories
listed in Exhibit 2C-3? (See end of instructions for exhibit.)
❑ Yes El No 4 SKIP to Item 7.8.
7.5
Have you checked "Testing Required" for all toxic metals, cyanide, and total phenols in Section 1 of Table B?
u,
❑ Yes ❑ No
7.6
List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s) identified
in Exhibit 2C-3.
Primary Industry Category
Required GCIMS Fraction(s)
Check applicable boxes.
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
❑ Volatile ❑ Acid ❑ Base/Neutral ❑ Pesticide
EPA Form 3510-2C (Revised 3-19) Page 4

EPA Identification Number
NPDES Permit Number
Facility Name
Form Approved 03/05/19
110022324607
NCO027197
City of Shelby Water Treatment
OMB No. 2040-0004
7.7
Have you checked "Testing Required" for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?
❑ Yes ❑ No
7.8
Have you checked 'Believed Present" or `Believed Absent' for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required?
0 Yes ❑ No
7.9
Have you provided (1) quantitative data for those Section 1, Table B, pollutants for which you have indicated testing is
required or (2) quantitative data or other required information for those Section 1, Table B, pollutants that you have
indicated are 'Believed Present' in your discharge?
0 Yes ❑ No
7.10
Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
❑ Yes 4 Note that you qualify at the top of Table B, ❑ No
'0
d
then SKIP to Item 7.12.
c'
7.11
Have you provided (1) quantitative data for those Sections 2 through 5, Table B, pollutants for which you have
c
determined testing is required or (2) quantitative data or an explanation for those Sections 2 through 5, Table B,
0
pollutants you have indicated are 'Believed Present' in your discharge?
N
Ma
El Yes El No
0
Table C. Certain Conventional and Non -Conventional Pollutants
7.12
Have you indicated whether pollutants are 'Believed Present' or "Believed Absent' for all pollutants listed on Table C
c
for all outfalls?
Y❑✓
Yes ❑ No
7.13
Have you completed Table C by providing (1) quantitative data for those pollutants that are limited either directly or
indirectly in an ELG and/or (2) quantitative data or an explanation for those pollutants for which you have indicated
"Believed Present'?
❑✓ Yes ❑ No
w
Table D.
Certain Hazardous Substances and Asbestos
7.14
Have you indicated whether pollutants are `Believed Present' or "Believed Absent' for all pollutants listed in Table D for
all outfalls?
❑ Yes No
7.15
Have you completed Table D by (1) describing the reasons the applicable pollutants are expected to be discharged
and (2) by providing quantitative data, if available?
❑ Yes ❑✓ No
Table E. 2,3 7,8-Tetrachlorodibenzo- Dioxin 2 3,7,8-TCDD
7.16
Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions, or do you
know or have reason to believe that TCDD is or may be present in the effluent?
❑ Yes 4 Complete Table E. ❑✓ No 4 SKIP to Section 8.
7.17
Have you completed Table E by reporting qualitative data for TCDD?
❑ Yes ❑ No
SECTIONOR
MANUFACTURED TOXICSi
Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
8.1
an intermediate or final product or byproduct?
❑ Yes ❑✓ No 4 SKIP to Section 9.
H
8.2
List the pollutants below.
c 2
1. 4. 7.
F0
0
2. 5. 8.
3. 6. 9.
EPA Form 3510-2C (Revised 3-19) Page 5

EPA Identification Number NPDES Permit Number Facility Name Form Approved 03/05/19
110022324607 NC0027197 City of Shelby Water Treatment OMB No. 2040-0004
SECTION• • • 1
9.1 Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on (1) any of your discharges or (2) on a receiving water in relation to your discharge?
❑ Yes ❑ No -* SKIP to Section 10.
H
qca
9.2
Identify the tests and their
ourposes below.
Submitted to NPDES
.5
Test(s)
Purpose of Test(s)
Permitting Authority?
Date Submitted
x
0
~
Chronic Toxicity TPG313
Permit Requirement
✓❑ Yes ❑ No
11/28/2022
0
m0
❑ Yes ❑ No
❑ Yes ❑ No
SECTIONi CONTRACT,
10.1
Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?
❑✓ Yes ❑ No 4 SKIP to Section 11.
10.2
Provide information for each contract laboratory or consulting
firm below.
Laboratory Number 1
Laboratory Number 2
Laboratory Number 3
Name of laboratory/firm
Pace Analytical
City of Shelby Waste Water
Plant
Z.Laboratory
address
2225 Riverside Drive,
1940 South Lafayette Street,
aAsheville,
INC, 28802
Shelby, NC, 28152
Va
126
0
c.�
Phone number
[phone]
7044846850
Pollutant(s) analyzed Total Copper, TOC, COD, BOD, Ammonia, TSS,
Toxicity, Fluoride, Total Turbidity,
Nitrogen, Phosphorus,
Aluminum
SECTIONDD
• •- • i
11.1
Has the NPDES permitting authority requested additional information?
❑ Yes ❑✓ No 4 SKIP to Section 12.
0
E
11.2
List the information requested and attach it to this application.
0
1. 4.
�o
0
2. 5.
a
3. 6.
EPA Form 3510-2C (Revised 3-19) Page 6

EPA Identification Number
NPDES Permit Number Facility Name Form Approved 03/05/19
110022324607
Shelby Water Treatment OMB No. 2040-0004
NCO027197 Lcit-y-f
SECTION•
1
12.1
In Column 1 below, mark the sections of Form 2C that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to complete all sections or provide attachments.
Column 1
Column 2
❑✓ Section 1: Outfall Location
❑ w/ attachments
❑✓ Section 2: Line Drawing
❑ w/ line drawing ❑ w/ additional attachments
Section 3: Average Flows and
w/ list of each user of
Treatment
❑ w/ attachments ❑ privately owned treatment
works
❑✓ Section 4: Intermittent Flows
❑ w/ attachments
❑� Section 5: Production
❑ w/ attachments
w/ optional additional
❑✓ Section 6: Improvements
❑✓ w/ attachments ❑ sheets describing any
additional pollution control
tans
❑ w/ request for a waiver and Elw/ explanation for identical
supporting information outfalls
w/ small business exemption
El ❑ wl other attachments
d
request
N
❑ Section 7: Effluent and Intake
❑✓ w/ Table A ❑✓ w/ Table B
C
Characteristics
0
❑✓ w/ Table C ❑ w/ Table D
d
w/ Table E w/ analytical results as an
❑ ❑
c�
attachment
❑ Section 8: Used or Manufactured
❑ w/ attachments
Toxics
❑ Section 9: Biological Toxicity
❑ w/ attachments
t
Tests
U
❑✓ Section 10: Contract Analyses
❑ w/ attachments
❑✓ Section 11: Additional Information
❑ w/ attachments
❑ Section 12: Checklist and
❑ yr/ attachments
Certification Statement
12.2
Certification Statement
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 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 fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
Brian Wilson
Water Resources Operations Manager
Signature
Date signed
ff
�2G�11i (�f/IL
03/02/2023
EPA Form 3510-2C (Revised 3-19) Page 7

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
110022324607 NCO027197 City of Shelby Water Treatment 001
Form Approved 03/05/19
OMB No. 2040-0004
TABLE A. CONVENTIONAL AND NON•
• POLLUTANTS
Effluent
Intake
Waiver
O tional
Maximum
Maximum
Long -Term
Pollutant
Requested
Units
(if applicable)
(specify)
Daily
Monthly
Average Daily
Number of
Long -Term
Number of
Discharge
Discharge
Discharge
Analyses
Average Value
Analyses
(required)
if available
if available
❑ Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.
1
Biochemical oxygen demand
❑
Concentration
mg/L
<2.0
1
Mass
mg
0
1
(BOD5)
2'
Chemical oxygen demand
❑
Concentration
mg/L
<25.0
1
Mass
mg
0.0
1
(COD)
Concentration
mg/L
<1.0
1
3.
Total organic carbon (TOC)
❑
Mass
mg
0.0
1
Concentration
mg/L
3.2
24
4.
Total suspended solids (TSS)
❑
Mass
g
2,140
24
Concentration
mg/1
<0.5
1
5.
Ammonia (as N)
❑
Mass
mg
0.0
1
6.
Flow
❑
Rate
MGD
.700
0.145
24
Temperature (winter)
❑
°C
°C
9
12
7.
Temperature (summer)
❑
°C
°C
27
12
pH (minimum)
❑
Standard units
S.U.
6.6
24
8.
pH (maximum)
❑
Standard units
s.U.
7.2
24
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 9

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
110022324607 NCO027197 City of Shelby Water Treatment 001
Form Approved 03/05/19
OMB No. 2040-0004
•
•
• • •'
Presence or Absence
• '• 11
Intake
check ones
Effluent
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long-
(and CAS Number, if available )
1E]
Required
q
Believed
Believed
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
DisQcharge
Discharge
Daily
Discharge
of
Analyses
Average
of
Analyses
( )
(ifavailablle)
if available
ee
Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.
Section 1. Toxic Metals, Cyanide, and Total Phenols
1.1
Antimony, total
Concentration
Mass
(7440-36-0)
1.2
Arsenic, total
El
IZI
Concentration
Mass
(7440-38-2)
1.3
Beryllium, total
Concentration
Mass
(7440-41-7)
1.4
Cadmium, total
El
El
El
Concentration
Mass
(7440-43-9)
1.5
Chromium, total
Concentration
Mass
(7440-47-3)
1.6
Copper, total
El
Concentration
ug/L
8
12
Mass
mg
9,797
12
(7440-50-8)
1.7
Lead, total
Concentration
Mass
(7439-92-1)
1.8
Mercury, total
El
El
IZI
Concentration
Mass
(7439-97-6)
1'9
Nickel, total
El
1:1
El
Concentration
Mass
(7440-02-0)
1.10
Selenium, total
0
Concentration
Mass
(7782-49-2)
1.11
Silver, total
Concentration
Mass
(7440-22-4)
EPA Form 3510-2C (Revised 3-19) Page 11

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
110022324607 NCO027197 City of Shelby Water Treatment 001
Form Approved 03/05/19
OMB No. 2040-0004
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
PollutantlParameter
(and CAS Number, if available)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
DisDail
Chayge
if available)Value
Number
of
Analyses
Long-
Term
Average
Number
of
Analyses
1.12
Thallium, total
(7440-28-0)
El
ID
Concentration
Mass
1.13
Zinc, total
(7440-66-6)
El
El
Concentration
Mass
1.14
Cyanide, total
(57-12-5)
❑
❑
❑✓
Concentration
Mass
1.15
Phenols, total
❑
❑
Z
Concentration
Mass
Section 2.Organic Toxic Pollutants (GCIMS Fraction
—Volatile Compounds)
2.1
Acrolein
(107-02-8)
Concentration
Mass
2.2
Acrylonitrile
(107-13-1)
❑
El0Concentration
Mass
2.3
Benzene
(71-43-2)
El
❑
❑
Concentration
Mass
2.4
Bromoform
(75-25-2)
❑
ID
Concentration
Mass
2.5
Carbon tetrachloride
(56-23-5)
❑
❑
❑✓
Concentration
Mass
2.6
Chlorobenzene
(108-90-7)
❑
❑
Concentration
Mass
2.7
Chlorodibromomethane
(124-48-1)
El
1:1Concentration
Mass
2.8
Chloroethane
(75-00-3)
El
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 12

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
110022324607 NCO027197 City of Shelby Water Treatment 001
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(speciry)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
Analyses
Long -
Term
Average
alue
Number
Of
Analyses
2.9
2-chloroethylvinyl ether
(110-75-8)
❑
❑
ID
Concentration
Mass
2.10
Chloroform (67-66-3)
❑
❑
IDConcentrationMass
211
Dichlorobromomethane
(75-27-4)
❑
❑
❑✓
Concentration
Mass
212
1,1-dichloroethane
(75-34-3)
Concentration
Mass
2.13
12-dichloroethane
(107-06-2)
El
❑
❑✓
Concentration
Mass
214
1,1-dichloroethylene
(75-35-4)
Concentration
Mass
2.15
1,2-dichloropropane
(78-87-5)
Concentration
Mass
2.16
13-dichloropropylene
(542-75-6)
Concentration
Mass
217
Ethylbenzene
(100-41-4)
Concentration
Mass
2.18
Methyl bromide
(74-83-9)
Concentration
Mass
2 19
Methyl chloride
(74-87-3)
Concentration
Mass
2.20
Methylene chloride
(75-09-2)
Concentration
Mass
2.21
1,1,2,2-tetrachloroethane
(79-34-5)
El
El
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 13

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
110022324607 NCO027197 City of Shelby Water Treatment 001
Form Approved 03/05/19
OMB No. 2040-0004
0 [ON
Pollutant/Parameter
(and CAS Number, if available)
(and
Testing
Required
kill
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Dailyof
Discharge
if available
Number
Analyses
Lon
Term
Average
Value
Number
Analyses
2 22
Tetrachloroethylene
(127-18-4)
Concentration
Mass
2.23
Toluene
(108-88-3)
❑
❑
Concentration
Mass
2.24
1,2-trans-dichloroethylene
(156-60-5)
❑
❑
❑✓
Concentration
Mass
225
1,1,1-trichloroethane
(71-55-6)
El
El
ID
Concentration
Mass
226
1,1,2-trichloroethane
(79-00-5)
❑
❑
ID
Concentration
Mass
-
2.27
Trichloroethylene
(79-01-6)
❑
❑✓
Concentration
Mass
2.28
Vinyl chloride
(75-01-4)
❑
❑
❑�
Concentration
Mass
Section 3.Organic Toxic Pollutants (GC/MS Fraction
—Acid Compounds)
3.1
2-chlorophenol
(95-57-8)
❑
❑
❑✓
Concentration
Mass
3.2
2,4-dichlorophenol
(120-83-2)
Concentration
Mass
3.3
2 4-dimethylphenol
(105-67-9)
Concentration
Mass
3.4
4,6-dinitro-o-cresol
(534-52-1)
Concentration
Mass
3.5
2,4-dinitrophenol
(51-28-5)
El
❑
✓❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 14

EPA Identification Number NPUES Permit Number Facility Name Outfall Number
110022324607 NCO027197 City of Shelby Water Treatment 001
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
and CAS Number, if available
( )
Testing
Required
q �
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
availablle
(if )
Long -Term
Average
Daily
Discharge
if available
Number
Analyses
Long-
Term
Average
Value
Number
of
Analyses
3.6
2-nitrophenol
(88-75-5)
El
Concentration
Mass
3.7
4-nitrophenol
(100-02-7)
Concentration
Mass
3.8
p-chloro-m-cresol
(59-50-7)
El
El
0
Concentration
Mass
3.9
Pentachlorophenol
(87-86-5)
1:1
ElEl
Concentration
Mass
3.10
Phenol
(108-95-2)IZI
Concentration
Mass
3.11
2,4,6-trichlorophenol
(88-05-2)
11
El
0
Concentration
Mass
Section 4.Organic Toxic Pollutants (GC/MS Fraction
—Base (Neutral
Compounds
4.1
Acenaphthene
(83-32-9)
E]
El0
Concentration
Mass
4.2
Acenaphthylene
(208-96-8)IZI
1:1Concentration
Mass
4.3
Anthracene
(120-12-7)
El
1:1O
Concentration
Mass
4.4
Benzidine
(92 87 5)IZI
Concentration
Mass
4.5
Benzo (a) anthracene
(56-55-3)
Concentration
Mass
4.6
Benzo (a) pyrene
(50-32-8)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 15

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
110022324607 NCO027197 City of Shelby Water Treatment 001
Form Approved 03/05/19
OMB No. 2040-0004
Poll utant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Discharge
if available
Number
of
Analyses
Long
Term
Average
Value
Number
of
Analyses
41.7
3,4-benzofluoranthene
(205-99-2)
Concentration
Mass
4.8
Benzo (ghi) perylene
(191-24-2)
❑
❑
❑✓
Concentration
Mass
4.9
Benzo (k) fluoranthene
(207-08-9)
0
El
✓
Concentration
Mass
4.10
Bis (2-chloroethoxy) methane
(111-91-1)
❑
❑
❑✓
Concentration
Mass
4.11
Bis (2-chloroethyl) ether
(111-44-4)
❑
❑
❑✓
Concentration
Mass
4.12
Bis (2-chloroisopropyl) ether
(102-80-1)
❑
❑
❑✓
Concentration
Mass
4.13
Bis (2-ethylhexyl) phthalate
(117-81-7)
❑
I✓
Concentration
Mass
4.14
4-bromophenyl phenyl ether
(101-55-3)
Concentration
Mass
4.15
Butyl benzyl phthalate
(85-68-7)
❑
❑✓
Concentration
Mass
4.16
2-chloronaphthalene
(91-58-7)
❑
El
IZI
Concentration
Mass
4.17
4-chlorophenyl phenyl ether
(7005-72-3)
El
El
✓
Concentration
Mass
4.18
Chrysene
(218-01-9)
❑
11
I✓
Concentration
Mass
4.19El
Dibenzo (a,h) anthracene
(53-70-3)
❑
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 16

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
110022324607 NCO027197 City of Shelby Water Treatment 001
Form Approved 03/05/19
OMB No. 2040-0004
Testing
q �
Required
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Pollutant/Parameter
and CAS Number, if available
( )
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Di hr a
i ischavailaarge
Number
of
Analyses
Long-
Term
Average
Value
Number
of
Analyses
4.20
12-dichlorobenzene
(95-50-1)
❑
❑
❑✓
Concentration
Mass
4.21
1,3-dichlorobenzene
(541-73-1)
❑
El
O
Concentration
Mass
4.22
1,4-dichlorobenzene
(106-46-7)
❑
❑
❑✓
Concentration
Mass
4.23
3,3-dichlorobenzidine
(91-94-1)
❑
❑
a
Concentration
Mass
4.24
Diethyl phthalate
(84-66-2)
©
Concentration
Mass
4.25
Dimethyl phthalate
(131-11-3)
Concentration
Mass
4.26
Di-n-butyl phthalate
(84-74-2)
❑
❑
©
Concentration
Mass
4.27
2 4-dinitrotoluene
(121-14-2)
❑
El
✓❑
Concentration
Mass
4.28
2 6-dinitrotoluene
(606-20-2)
El
❑
IZI
Concentration
Mass
4.29
Di-n-octyl phthalate
(117-84-0)
❑✓
Concentration
Mass
4.30
1,2-Diphenylhydrazine
(as azobenzene) (122-66-7)
Concentration
Mass
4.31
Fluoranthene
(206-44-0)
❑
❑
Concentration
Mass
4.32
Fluorene
(86-73-7)
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 17

EPA Identification Number NPOE6 Permit Number Facility Name Outfall Number
110022324607 NCO027197 City of Shelby Water Treatment 001
Form Approved 03/05/19
OMB No. 2040-0004
Poll utant/Parameter
(and CAS Number, if available)
Testing
Required
Presence or Absence
check one
Units
Effluent
Intake
(optional)
Believed
Present
Believed(specify)Maximum
Absent
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if available)
Long -Term
Average
Daily
Discharge
if available
Number
of
Analyses
Long(specify)Number
Term
Average
Value
of
Analyses
4.33
Hexachlorobenzene
(118-74-1)
_
✓
Concentration
Mass
4.34
Hexachlorobutadiene
(87-68-3)
❑
0
❑✓
Concentration
Mass
4.35
Hexachlorocyclopentadiene
(77-47-4)
❑
❑
❑✓
Concentration
Mass
4.36
Hexachloroethane
(67-72-1)
❑
❑
❑✓
Concentration
Mass
4.37
Indeno (1,2,3-cd) pyrene
(193-39-5)
❑
❑✓
Concentration
Mass
4.38
Isophorone
(78-59-1)
El
❑
❑✓
Concentration
Mass
4.39
Naphthalene
(91-20-3)
El
❑
✓
Concentration
Mass
4.40
Nitrobenzene
(98-95-3)
El
❑
❑✓
Concentration
Mass
4.41
N-nitrosodimethylamine
(62-75-9)
❑
❑
0✓
Concentration
Mass
4.42
N-nitrosodi-n-propylamine
(621-64-7)
El
El
Concentration
Mass
4.43
N-nitrosodiphenylamine
(86-30-6)
Concentration
Mass
4.44
Phenanthrene
(85-01-8)
✓
Concentration
Mass
4.45
Pyrene
(129-00-0)
❑
I✓
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 18

EPA Identification Number NPDES Permit Number Facility Name
Outfall Number Form Approved 03/05/19
110022324607 NC0027197 City of Shelby Water Treatment
001 OMB No. 2040-0004
Presence or Absence
check one
Effluent Intake
(optional)
Pollutant/Parameter Testing Units
�
Maximum
Maximum
Long -Term
Long-
and CAS Number, if available Required Believed Believed
( ) q (specify)
1
Daily
Monthly
Average
Number
Term
Number
Present Absent
Discharge
aily
of
Average
of
(required)
(if )
DisDcharge
Analyses
Analyses
if available
.46 1,2,4-trichlorobenzene
4.461
El
El
0Concentration
EMass
(120-82-1)
Section 5.Organic Toxic Pollutants (GCIMS Fraction
—Pesticides)
51
Aldrin
❑
❑
❑✓
Concentration
Mass
(309-00-2)
5.2
a-BHC
Concentration
Mass
(319-84-6)
5.3
R-BHC
❑
❑
❑
Concentration
Mass
(319-85-7)
5.4
y-BHC
El
El
ID
Concentration
Mass
(58-89-9)
5.5
b-BHC
El
❑
❑
Concentration
Mass
(319-86-8)
5.6
Chlordane
❑
❑
0
Concentration
Mass
(57-74-9)
5.7
4,4'-DDT
❑
❑
❑
Concentration
Mass
(50-29-3)
5.8
4,4'-DDE
❑
❑
❑
Concentration
Mass
(72-55-9)
5.9
4,4'-DDD
❑
❑
O
Concentration
Mass
(72-54-8)
5.10
Dieldrin
❑
❑
✓
❑
Concentration
Mass
(60-57-1)
5.11
a-endosulfan
❑
❑
✓
❑
Concentration
Mass
(115-29-7)
EPA Form 3510-2C (Revised 3-19) Page 19

EHA Identiticatlon Number NNUL6 Hermit Number Facility Name Uuttall Number
110022324607 NCO027197 City of Shelby Water Treatment 001
Form Approved 03/05/19
OMB No. 2040-0004
Pollutant/Parameter
and CAS Number, if available
( )
Testing
Required
q '
Presence or Absence
check one
Units
(specify)
Effluent
Intake
(optional)
Believed
Present
Believed
Absent
Maximum
Daily
Discharge
(required)
Maximum
Monthly
Discharge
(if a )
Long -Term
Average
Daily
Discharge
if available
Number
Analyses
Long-
Term
Average
Number
of
Analyses
5.12
(3-endosulfan
(115-29-7)
El
ElMass
IZI
Concentration
5.13
Endosulfan sulfate
(1031-07-8)
El
1:1
ID
Concentration
Mass
5.14
Endrin
(72-20-8)
El
El❑
Concentration
Mass
5.15
Endrin aldehyde
(7421-93-4)
El
❑
ID
Concentration
Mass
5.16
Heptachlor
(76-44-8)
❑
❑
✓
❑
Concentration
Mass
5.17
Heptachlor epoxide
(1024-57-3)
El
El
IZI
Concentration
Mass
5.18
PCB-1242
(53469-21-9)
El
❑
Concentration
Mass
5.19
PCB-1254
(11097-69-1)
El
❑
0
Concentration
Mass
5.20
PCB-1221
(11104-28-2)
❑
El
Concentration
Mass
5.21
PCB-1232
(11141-16-5)
0
❑
IZI
Concentration
Mass
5.22
PCB-1248
(12672-29-6)
El
❑
Concentration
Mass
5.23
PCB-1260
(11096-82-5)
❑
❑El
Concentration
Mass
5.24
PCB-1016
(12674-11-2)
0
El
El
Concentration
I
Mass
EPA Form 3510-2C (Revised 3-19) Page 20

EPA Identification Number NPUES Permit Number
110022324607 NCO027197
Name
City of Shelby Water Treatment
ill Number
001
Form Approved 03/05/19
OMB No. 2040-0004
Presence or Absence
check one
Effluent
Intake
(optional)
Pollutant/Parameter
Testing
Units
Maximum
Maximum
Long -Term
Long -
(and CAS Number if available)
(and
Required
Believed
Believed
s
(specify)
Daily
Monthly
Average
Number
Term
Number
Present
Absent
Discharge
Discharge
aily
of
Average
of
(required)
(if available)
Discharge a
Analyses
Analyses
if available)
Toxaphene
5.25
✓❑
Concentration
Mass
(80O1-35-2)
' Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 21

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110022324607 NCO027197 City of Shelby Water Treatment 001 OMB No. 2040 0004
• • • • • •• 1
Presence or Absence
Intake
check one Effluent
(Optional)
Units
PollutantMaximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
(required) Discharge Discharge Analyses Analyses
Value
if available if available
❑ Check here if you believe all pollutants on Table C to be present in your discharge from the noted outfall. You need not complete the 'Presence or Absence" column of Table C for
each pollutant.
❑ Check here if you believe all pollutants on Table C to be absent in your discharge from the noted outfall. You need not complete the "Presence or Absence" column of Table C for
each pollutant.
1
Bromide
❑
❑
Concentration
Mass
(24959-67-9)
2
Chlorine, total
❑
❑
Concentration
ug/L
18
24
Mass
mg
6,104
24
residual
3.
Color
❑
❑✓
Concentration
Mass
4.
Fecal coliform
El❑✓
Concentration
Mass
5
Fluoride
❑
❑
Concentration
ug/L
130
4
Mass
mg
127,358
4
(16984-48-8)
6
Nitrate -nitrite
❑
❑✓
Concentration
Mass
7.
Nitrogen, total
❑
Concentration
mg/L
0.580
4
Mass
mg
985,269
4
organic (as N)
8.
Oil and grease
❑
Concentration
Mass
9
Phosphorus (as
❑
❑
Concentration
mg/L
<0.05
4
Mass
mg
0.0
4
P), total (7723-14-0)
10
Sulfate (as SO4)
❑
❑
Concentration
Mass
(14808-79-8)
11.
Sulfide (as S)
❑
Concentration
Mass
EPA Form 3510-2C (Revised 3-19) Page 23

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110022324607 NCO027197 City of Shelby Water Treatment 001 OMB No. 2040-0004
Presence or Absence Intake
check one Effluent
(Optional)
Units
Pollutant Maximum Long -Term
Believed Believed (specify) Maximum Daily Long -Term
Monthly Average Daily Number of Number of
Present Absent Discharge Average
Discharge Discharge Analyses Analyses
(required) if available if available Value
12
Sulfite (as S03)
❑
❑
Concentration
(14265-45-3)
Mass
13.
Surfactants
El
�
Concentration
Mass
- --
14.
Aluminum, total
❑✓
❑
Concentration
ug/L
250
4
(7429-90-5)
Mass
mg
225,295
4
15.
Barium, total
❑
❑
Concentration
(7440-39-3)
Mass
16.
Boron total
El
ID
Concentration
(7440-42-8)
Mass
17.
Cobalt, total
El
❑✓
Concentration
(7440A8-4)
Mass
18
Iron, total
❑
❑
Concentration
(7439-89-6)
Mass
19
Magnesium, total
❑
❑✓
Concentration
(7439-95-4)
Mass
Molybdenum,
Concentration
20.
total
7439-98-7
Mass
21
Manganese, total
❑
❑
Concentration
Mass
(7439-96-5)
22
Tin, total
❑
❑
Concentration
(7440-31-5)
Mass
23
Titanium, total
❑
❑
Concentration
(7440-32-6)
Mass
EPA Form 3510-2C (Revised 3-19) Page 24

EPA Identification Number
NPDES Permit Number
Facility Name
Outfall Number
Form Approved 03/05119
110022324607
NCO027197
City of Shelby Water Treatment
001
OMB No. 2040-0004
•
•r-M
• •
• '•
I
Presence or Absence
Intake
check
one
Effluent
(Optional)
Pollutant
Believed
Believed
Units
(specify)
Maximum Daily
Maximum Long -Term
Long -Term
Present
Absent
Discharge
Monthly Average Daily Number of
I Number of
I Average
(required) )
Discharge Discharge Analyses
Analyses
if available if available)Value
24. Radioactivity
Alpha, total
El
❑✓
Concentration
-- -----------
Mass
Beta, total
❑
❑✓
Concentration
-
Mass
---
Radium, total
❑
�
Concentration
Mass
Radium 226, total
❑
❑✓
Concentration
Mass
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 25

EPA Identification Number NPDES Permit Number Facility Name Outfall Number
11nr»iaiarn7 I Nrnn)7l97 I rit fcr,eik %AI,t-T,-,r..--+ I nn1
Form Approved 03/05/19
OMB No. 2040-0004
'B•
Pollutant
• 1
Presence or Absence
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
(specify units)
Believed
Present
Believed
Absent
1.
Asbestos
❑
❑
❑
2.
Acetaldehyde
❑
3.
Allyl alcohol
❑
❑
4.
Allyl chloride
❑
❑
❑
5.
Amyl acetate
❑
6.
Aniline
❑
❑
7.
Benzonitrile
❑
❑
8.
Benzyl chloride
❑
❑
9.
Butyl acetate
❑
❑
10.
Butylamine
❑
❑
11.
Captain
❑
❑
12.
Carbaryl
❑
❑
13.
Carbofuran
❑
❑
14.
Carbon disulfide
❑
❑
15.
Chlorpyrifos
❑
❑
16.
Coumaphos
❑
❑
17.
Cresol
❑
❑
18.
Crotonaldehyde
❑
❑
19.
Cyclohexane
❑
❑
EPA Form 3510-2C (Revised 3-19) Page 27

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03/05/19
110022324607 NCO027197 City of Shelby Water Treatment 001 OMB No. 2040-0004
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
20.
1Dichlobenil
2,4-D (2,4-dichlorophenoxyacetic acid)
❑
❑
❑
❑
❑
❑
❑
❑
❑
1.
21.1
Diazinon
22.
Dicamba
El❑
23.
❑
24.
Dichlone
❑
25.
2,2-dichloropro pion ic acid
❑
26.
Dichlorvos
❑
27.
Diethyl amine
❑
28.
Dimethyl amine
❑
❑
29.
Dintrobenzene
❑
❑
30.
Diquat
❑
❑
31.
Disulfoton
❑
❑
32.
Diuron
❑
❑
33.
Epichlorohydrin
❑
❑
34.
Ethion
❑
❑
35.
Ethylene diamine
❑
❑
36.
Ethylene dibromide
❑
❑
37.
Formaldehyde
❑
❑
38.
Furfural
❑
❑
EPA Form 3510-2C (Revised 3-19) Page 28

EPA Identification Number NPDES Permit Number Facility Name Outfall Number FormApproved 03/05119
110022324607 NCO027197 City of Shelby Water Treatment 001 OMB No. 2040-0004
'It l • if arn
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
39.
Guthion
Isoprene
❑
❑
❑
❑
40.
41.
Isopropanolamine
❑
❑
42.
Kelthane
❑
❑
43.
Kepone
❑
❑
44.
Malathion
❑
❑
45.
Mercaptodimethur
❑
❑
46.
Methoxychlor
❑
❑
47.
Methyl mercaptan
❑
❑
48.
Methyl methacrylate
❑
❑
49.
Methyl parathion
❑
❑
50.
Mevinphos
❑
❑
51.
Mexacarbate
❑
❑
52.
Monoethyl amine
❑
❑
53.
Monomethyl amine
❑
❑
54.
Naled
❑
❑
55.
Naphthenic acid
❑
❑
56.
Nitrotoluene
❑
❑
57.
Parathion
❑
❑
EPA Form 3510-2C (Revised 3-19) Page 29

EPA Identification Number NPDES Permit Number Facility Name Outfall Number Form Approved 03I05/19
110022324607 NCO027197 City of Shelby Water Treatment 001 OMB No. 2040-0004
0 1
Presence or Absence
Pollutant check one Available Quantitative Data
Believed Believed Reason Pollutant Believed Present in Discharge (specify units)
Present Absent
58.
Phenolsulfonate
❑
❑
❑
59.
Phosgene
❑
60.
Propargite
❑
❑
61.
Propylene oxide
❑
❑
62.
Pyrethrins
❑
❑
63.
Quinoline
❑
❑
64.
Resorcinol
❑
❑
65.
Strontium
❑
❑
66.
Strychnine
❑
❑
67.
Styrene
❑
❑
68
2,4,5-T (2,4,5-trichlorophenoxyacetic
acid
❑
❑
69.
TDE (tetrachlorodiphenyl ethane)
❑
❑
70.
2,4,5-TP [2-(2,4,5-trichlorophenoxy)
ro anoic acid
❑
❑
71.
Trichlorofon
❑
❑
72.
Triethanolamine
❑
❑
73.
Triethylamine
❑
❑
74.
Trimethylamine
❑
❑
75.
Uranium
❑
❑
76.
Vanadium
❑
❑
EPA Form 3510-2C (Revised 3-19) Page 30

EPA Identification Number
NPDES Permit Number
Facility Name Outfall Number
Form Approved 03/05/19
110022324607
NCO027197
City of Shelby Water Treatment 001
OMB No. 2040-0004
.:
Milig
I•
1
Presence or Absence
Pollutant
check one
Reason Pollutant Believed Present in Discharge
Available Quantitative Data
Believed
Believed
(specify units)
Present
Absent
77.
Vinyl acetate
❑
❑
78.
Xylene
❑
❑
79.
Xylenol
❑
❑
80.
Zirconium
❑
❑
I Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
EPA Form 3510-2C (Revised 3-19) Page 31

City of Shelby WTP NPDES Renewal 2023
Additional Text — Form 1 and Form 2
Form 1
Facility Name: City of Shelby Water Treatment Plant
Form 2C
Facility Name: City of Shelby Water Treatment Plant
Section 1.1: Un-Named Tributary of the First Broad River
Section 3.1 Treatment Units: Flocculation - 12 Flocculators, approximately 171,333 Gallons, Average
Daily Flow of 5.3 MG, approximately 46 minutes of Retention Time
Section 3.1 Treatment Units: Sedimentation - 10 Settling Basins, approximately 1,649,499 Gallons,
Average Daily Flow 5.3 MG, approximately 7.38 Hours of Retention Time
Section 3.1 Treatment Units: Filtration - 8 Multi -Media Filters, 360 Square Feet of Surface Area per
Filter, Maximum Flow rate of 1,440 GPM, Average Daily Flow of 5.3 MG, Average Daily Flow of 1.29
Gallons per Square Foot per Filter
Section 3.1 Treatment Units: De -Chlorination - consist of two bulk Sodium Thiosulfate storage tanks,
one metering pump set a feed rate of 105 mL per minute, 5 gallons of carrier water per minute, runs 1
hour per day.

Ecn,,rown.14ant.nc.
RO, Box 1E414 Greenv Ile SIC 29606
(G64) 877.6c,,42 . FAX [phone]
4 Craftsman Ctur., Greer, SC 29650
Ceriodaphnia dubia Survival and Reproduction Test
EPA-821-R-02-013 Method 1002
Client: CITY OF SHELBY
Facility: WTP
NPDES #: NCO027197
Test Date: 19-Oct-22
Laboratory ID #: T63237
Test Reviewed and Approved By:
414
Robert W. Kelley, Ph.D.
President
4p,
Certification #E87819
Test results presented in this report conform to all requirements of
NELAC, conducted under NELAC Certification Number E87819
Florida Dept. of Health. Included results pertain only to provided sa les.
age 1 of 6
I�4 1P. 6""' ,
Patrick D. Timms
QA/QC Officer
SCDHEC Certification #23104
NCDENR Certification # 022 Page 8 of 13

Effluent Toxicity Report Form - Chronic Pass/Fail and Acute LC50
Date 01-Nov-22
Facility: CITY OF SHELBY WTP NPDES#NC0027197 Pipe# 001 County: Cleveland
Laboratory Performing Test: comments
X
Signature of Operator in Responsible Charge X A��
".
!Signature of Laboratory Supervisor
MAIL ORIGINAL TO
North Carolina Ceriodaphnia Chronic Pass/Fail Reproduction Toxicity Test
CONTROL ORGANISMS
# Young Produced
Adult (L)ive (D)ead
Effluent %
TREATMENT 2 ORGANISMS
# Young Produced
Adult (L)ive (D)ead
Environmental Sciences Branch
Div. of Water Quality
N.C. DENR
1621 Mail Service Center
Raleigh, North Carolina 27699-1621
Chronic Test Results
Calculated t= 0.3141
Critical Value= 2.508
1 2 3 4 5 6 7 8 9 10 11 12 % Reduction= 0.8%
20
21
22
21
21
22
20
19
19
19
23
22
L
L
L
L
L
L
L
L
L
L
L
L
1 2 3 d 5 fi 7 A 9 1n 11 12
20
21
21
20
23
21
20
21
18
20
20
22
L
L
L
L
L
L
L
L
L
L
L
L
Complete This for Either Test
CollectionfStart) Date
pH 1st sample 1st sample 2nd sample Sample 1 18-Oct-22
Control 7.8 8.2 7.7 7.9 7.8 8.0 m I n
Treatment 2 7.3 8.0 7.5 7.4 7.2 7.4 Grab con
Sample 1 1 X
Sample 2 X
start end start end start end
D.O. tst sam le 1st sam le 2nd sam le Hardness (mg/L)
Control 8.0 8.7 8.1 7.8 8.4 8.2 Spec. Cond. (pmhos)
Treatment 2 8.6 8.6 9.3 8.2 9.0 8.3 Chlorine (mg/L)
Sample Temp. at receipt (°C)
LC50/Acute Toxicity Test
(Mortality expressed as %, combining replicates)
LC50 = %
95%Confidence Limits
Oraanism Tested
Method of Determination
Average Probit
an Karber ROther
dubia
DEM Form AT-1
Page 2 of 6
0%
20.8
Control
Control
0%
20.6
reatment 2
Treatment 2
ontrol CV
6.5%
PASS FAIL
% 3rd Brood
X
100%
IIIIIIIIIN
Test Start Date
19-Oct-22
Samole 2 20-Oct-22
on 1st 2nd
Tox Tox
Dilution Sample Sample
81.6
304 108 108
2.1 1 0.6
start/end starUend
Control
High Conic
pH D.O.
Page 9 of 13

STATISTICAL ANALYSIS RESULTS
Facility: CITY OF SHELBY NPDES# NCO027197
Sample ID: WTP Err# T63237 Date: 19-Oct-22
Laboratory: Certification #: NCO22 I Ex . Date: 11/1/2022
Survival Data
7 Day Survival
Test Used: FISHERS TEST
Control 100%
Test Statistic: P= 1.000
Effluent 100%
Critical Value: P 0.01
PASS: The effluent does not reduce survival of the test organisms.
Reproduction Data
Raw Data
Test for Normality
Mean young/female
Std. Dev.
Test Used: Shapiro-Wilks Test:
Control
20.8 1.36
Effluent
20.6 1.24
W:
0.964
Critical Value:
0.884
Analysisfor Differences in Reproduction
Test for Homogeneity of Variance
Test Used: Equal Variance t Test.
Test Used: F Test
Calculated t=
0.31
F=
1.20
Critical Value=
2.51
Critical Value=
5.32
The data are homogeneous in variance
PASS: The effluent is not chronically toxic.
Page 10 of 13
Page 3 of 6

Control Mortality and Reproduction by Test Day
1 2 3 4 5 6 7 8
Total
source
rep
117 1-12
1
3
+7+10
20
HH7 10-1
2
+3+7
11
21
T1 10-7
3
+3+8
11
22
X8 10-7
4
+4+7
10
21
N4 10-6
5
+3+6
12
1 21
X4 10-7
6
+4+7
11
22
P8 10-6
7
+4+5
11
20
F4 10-7
8
3
+6+10
19
E3 10-7
9
3
+7+9
19
K2 10-6
10
+3+5
11
19
L8 10-6
11
+4+7
12
23
110 10-6
12
+3+7
12
22
13
N/A
0
14
N/A
0
15
N/A
0
16
N/A
0
17
N/A
0
18
N/A
0
19
N/A
o
Mean
20
N/A
0
20.8
90 % Effluent Mortality and Reproduction by Test Day
1 2 3 4 5 6 7 8
Total
LL7 1-1
1
+3+7
101
20
HH710
2
+4+7
101
21
T1 10-7
3
+3+7
11
21
X8 10-7
4
+3+7
10
20
N 4 10-6
5
+4+8
11
23
X4 10-7
6
+3+7
11
21
P810-6
7
1
+4+6
1
10
20
F410-7
8
+3+7
11
21
E 3 10-7
9
+3+6
91
18
K2 10-6
10
+4+5
11
20
L8 10-6
11
+4+5
11
20
110 10-E
12
+4+7
11
22
0
13
N/A
0
0
14
N/A
0
0
15
N/A
0
0
16
N/A
I0
O
/A0
/A
o
Mean
0
J17/A0
/A
0
20.6
JC
AM
n ate
ed JZ
JC26-Oct-22
time fed & renew2:03 PM
0149 PM
09:50 AM
00 50 AM
11 49 AA'
1 .11
JZ
New temp. "C
24.7
25.1
Old temp. C
24.6
25.4
25.3
Control New temp- �C
24.6
1
24.5
MAR 0 8 2023
Lab#
T63237
Client
CITY OF SHELBY
Sample ID
WTP
NPDES#
NCO027197
County
Cleveland
Month
10
Start & fed Date
19-Oct-22
Start & fed Time
Started & fed By
03:45 PM
AM
Test Organism
Neo. born date
Ceriodaphnia dill
18-Oct-22
Neo. born time
1645-2200
Test Type
NCCPF
Dilution Water
Units for Conc.
MHSF
%
IWC
%3rd BROOD
90
Test vessels
30 ml
Test volume
15 not
Incubator#
1
Light
161t/8dk
Initial Temp °C
24.8
Selenastrum
0.05 ml
YAT
0.05 ml
Test method il
FA 921 R 02 013:1002
=Dead N/A -Lost or not used
Page 11 of 13
Page 4 of 6

Bioassay Chain Of Custody Form
Facillij Wine:_ LJ("
Addre,- L; P.O. Box.,
Phone
Contact:
County: NPDES pernit V7 i 'i Z_ pipo:
% Effluent Dilution (lWc): c) pla6t flow.
Select I est Method.
11C. dubi3 Pass/Fail clwonio 000GPFGNC J_J Rproinolas Paso/Fall Acuto OOOA PFPpr
El C-dU614 Full Rain'a'e Chronic 6WG FRCNC 13 Rprornalac Full Rango Acute 600A FRPpr
El C, clubla Pass/Fall Awto 000A PFCdv ❑ Rip , roinclaG Frill Rungo Chronic 821C FRPpr
13 14. bohla Pan/Fall Acute 600A PFMba
Sample olfector Print Z0117 19
Signature yl 1, A&Z'
Q­1- M­
compos
to
1"10 -9 j
Date
Dafe
Started
Ended
Time;
Time:
AM or PM
AM or PM -
PM: Silo Due Date: 11/08/22
Samples
per Hr;
Hra:
CLIEN'r: 93-Shelbv WT
GrA
/0 It- L:L
X. Date: 2-
ky.ime:
AU2—@or PM
0 15 1
Sample
Volume:
Chilled
during Collectiod?
Yes or No
ie Lab.__
('.hnh of rf izfe-wht PnfnncR
.. . . . . . . . . . . . . .......
Common
a . I " C a� E IT
Pace Work Order Number.
.. Received
RewivinC Temperature:
.B � /N��}, 1 c•Z(:� �-�,%�. �t� i`7/?'L � � 7J''
renooDr.,*Rate�h,-NO27007Phone:oib)n4A�1(4",'-'."
FiCe/sula."cal -Services, Inc. Address: 6701 Confo
Page 12 of 13
Page 5 of 6

Noassay Chair? of custody Form
�s�sl
r.. Facillt Npme: ry , � o'F 5" zv7 • � bell•• a•
c.D/ P.O. BOX:• lJ irrGru�i �S {
Addre s• oc
Photte 7F: •_ Co,
Contact
pipe:
1 NPDES permit ff; �
0o�
County :� zl =��-.�-.----•-
9 {'lath Flow:
% Eft, nt Dilution (IWC):
800A PFPpr
Soled est Method: QQOCPFCNG P-Komotae -ull Roil Acute 6" FRPpr
C. dubla Aass/Fall Gu'only 60(1C FRCN ❑ P.pron►elac i`ull RFmgo Acute 8210 FRPpr
13 C. dubia Full Range Chronic ❑ P•promelas Full Rama Chronic
p C. dubiai Pass/FlIll Acute OQOA PFCdu
❑ M. bahla r'uoe/Fap Route 800A PFMba .
Sample ollectoc print
=r Signature
Compos to Time: AM or PM
ate Started _ =- — Time: ___^_ _ AM or PM '
a(e Ended ------ Hrs:
amples per Hr: - -----
Grab Time: �cati M or PM
x. Rate: - Z o - t z �.. --
Collectloh? yes or No
Chilled during
Sample Volutttc�:. � � -
MAW
�r
Comments
Far Pace AnalytIcal, Inc, Use Qn►Y
Pace Wor1c rder Number: Received.
Receivin Temperature: ,
:..
• ..-.. P.•. 'te nalyKcal Services. Inc. Address: 6701 Confe.,
rence Dr
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-� Page 13 of 13
Page 6 of 6

aceAnalytical
www.pacalabs.cao
Laboratory Report
Mr. Billy Wilkie
City of Shelby WTP
P.O. Box 207
Shelby, NC 28151
Project: Toxicity NC0027197
Pace Project No.: 92631569
Reviewed by: Z��
Sarah Graham
[phone]
[e-mail]
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Page 1 of 1
Report Date: 11 /09/2022
Date Received: 10/18/2022
Page 1 of 13

c e - U(;#--Fitle: ENV-FRM-HUNI-0083 01—Sample Condition Upon Receipt
Effecting Date: 051121202205/1�/01621
Laboratory receiving sample;-
Ashevillell, EdenEl GreeinwoodO HUMersvilleV Raleigh[] Mechanicsvillen AtlantaM Ke rnomiWilaM
Sample Condition Client NaPie-. nn WO#
Project . -92631569
Upor I Receipt J #: :
Courier: Oyed Ex—EJUP.T E3USPJ --[n—client
0 commercial (ace . ©Other,
Custody Seal Present? O.yes G/No Seals Intact? Elyes D(No
. Packing Material: E311ubble Wrap ElBubble Bags E?(N.ne [-] Other
the tr.
rM"Y,RGU,.,D, Q "-tl�
Type ofIce: a/wet
Cooler Temp:Correction Factor.
Add/Subtract(T)
Cooler Ternp Corrected (Cl- 10. DA
USDA Regulated Sall (0.14/jk water sample)
01diamples4riginate in a quarantine zone within the United States: CA, NY, 0SOC
khL-ck:mark1.7f7Y,-c !`-Ihi�
OBlue OlTone
BlologlcalTksue rozeni?
CY-es []NO P',A
T.04pshould be,aiticivefroe2lA9 tQ6*C
DamPlet Out bfteMp criteria. Sampfes.on ice, cooling. process
has begun
Did samples OgWte from. it 11breth source (Mtemitio,0611y;
nowan driu rueFtu micoly, 1 _lM UNO
Comments/Discrepancy:
Chain of Custody Present?
14yes
ONo 014/A
SamOes Arrived within Hold Time?
Yes
QNO CjNlA
2.
Short: Hold Time Analysis
Yes
O
ElNOPto n41A
N/A
1,
Rush -Turn Aroraid Time. Requested?
r-1...
A.. QN/A
4.
Sufficient Volume?
Ely"
No EINA
S'
correct Contalners; Used?
es
Oft ON[A
6
-Pace Containers Used?
es
131140 QN/A
Containers intact?
es
QNo LIN/A.
7.
Qissoived analysis: SamplesVeld Filtered?
clym
No: CiN/A
9:,
'Sample LaWls match Coc?
ElYeS
ONo ONJA
-9,
-Includes DaLe/Tiip 6/(D/Analysis NUtrlx-.—
"Wspace 11) VGA ylat's. (>S-6 rnrnp;
Q Yes
No. 6-NIA,
16.
TrI10.8lank Present?
[]Yes
ONO MN
/A
11.
Trip;Slapk Custody Seals Present?
QYes
No dN/A
DI w nMCDCDAInN
COMMENTS/SA
Lot 10 oft-splitcop01ners:
CUEW, NOTIFICATION/RESOLUTION
Person corftacted:
Project Manager SCURF Review:
Date/Time-
Date:
Date.--- -
Field Data Required? HYes [--INo
Page 2 of 13
.,QualtraX 1D.- 69614 Page-1 of 2

face UcENV-Title:-HUNI.0083 v01_Sample Condition Upon Receipt
Effective Date: 05112/202205/12/2022
*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, oil and Grease, DRO/8015 (water) DOC, LLHg
"Bottom half of box is to list number of bottles
***Check all unpreserved Nitrates for chlorine
Project : WOE# : 92'631569
PM: SMG Due Date: 11/08/22
CLIENT: 83-Shelby WT
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PH Adjustment Log for Preserved Samples
Sample ID Type of Preservative pH upon receipt Date preservation adjusted Time preservatlon Amount of Preservative tot q
adjusted added
Note Whiir'V27i ere is a�iscrepantjr a" #Fecting North Carolina compliance samples, a Copy of this farm will be sent to the North Carolina DENR Certification Office {i.e,
Out of hold, incorrect preservative, out of temp, incorrect containers.
Qualtrax ID: 69614 Page 2 of 2 Page 3 of 13

Bioassay Chain of Custody Form
Facilit Name:
Addre s: G l:i ,• , , " , P.O. Box; �L 07 e% r N 1 S1S%
Sbedb,y VC Z 9/.fC Phone Ky'6
T Contact. /a i1 y k),A-; C
County: clevek"I NPDES permit #: AC do -47 M Z pipe: 001
Efflu int Dilution (IWC): C PlahtFlow..
Select I est Method:
C, du6la Pass/Fall Chmr4o 000CPFCNC El P.promeles Pass/Fall Acute 600A PFPpr
© C. dubla Full Range Chronic 600C FRCN © P.prornelas FW Range Acute 600A FRPpr
❑ C, dubla PassTall Acute 600A PFCdu P.pmeras Full Range Chronic 8210 FRPpr
Q M. bahia Pas&*afl Acute 600A PFMba
Sample ollector Print
, Signs
ate Started nme: AM or PM
ate Ended Time: AM or PM
srnples per Hr. # Nrs:
Grab /0 - /Jr. L t
X, Date: - / $ -Z Z. , Time, -9-� or PM
Sample Volume:. 1 4 Chilled during Collection?
Aii4...ei :tt .. ro:•-�-,-r�r:.: e:t iL..�.'1 ,. t`.. ..'`r� .l" _.. - ..
r',hnln of r'.rretnriv RwWMA
WO# : 92'631569
PM: Sidi Due Date: 11/08/22
CLIENT: 93-Shelby WT
Yes or No
Iran
For Pace Anatyt:Ical, Inc. Use Only
Pace Work Order Number
Recelvm TemAerature: 0.5 Received. By , zA/t�i(,
..�
�eAna"cW Services. Inc. Addrm: 6701 Corifemnos DC.;•Raf gh 1VC 77607 Pfione:,(9t8)$34=4M* 'r" : • ,
_ Page 4 of 13

UC#_Title; ENV-FRM-HUN1-0083 v01_Sample Condition Upon Receipt
Idl CO.
! iwetxunmir
_ I
Laboratory rece;ivingsarnples:
Asheville [J EdenO GreehWdod-0 .,F�tintersville Raleigh❑ MechanicsvilleF-] Atianta0 Kernersvifle�
Snnipfc .ition i�e�t(Na .. W0.#:.: 92631569 -
. Upon Receipt Gl• � Scut Project is
Ca Corn; e[da. UPS;. [] SPs OClient ❑ Commercial Pace ❑Other. 926315SO
Custody Seal Present.? QYes do Seals intact? QYes No .nn
pelts/IiNtiaiaRersonEi�aminingCnr�tants: N' _ �b
Packing Material: 08ubtille4trap [Bubble Bags [None Q Other Biological Tlssu Frozen?
Thermo me r: []Ye$ ❑NO MNfk
IR Gun IQ: }�
- C121%* Type of ke: dwIt Blue []None
— — erection Fip;tor:
Cooler Temp; Atdd/SBbudtC;{'C) —0 'romp should be above freezing to 6'
[]Samples out oftempsrKeria. Samples on ice, cooling.process
Cooler TempCorrected}: 2, 1 has begun
USDA Regulated Soil ( N/ water sample)
V1H iarUP(Ca U,;1MJF JOIC 1r, d
check,maps)? ❑Yes
uaranune xem wimin me. umteaabtateS: EA;.gy or sr-
No
Did samples originate from a foreign source Omer tlonalty,.
including Hawed and Puerto Rica)? Dyes Na.
Comments/Discrepancy-
Chain of Custod[V R pentT
s
ONO ..
(IN/A
1,
Samples Arrived wititin:Hold Time?:
des.
ONo
[)N/A.
2+
Short Hold Tune At�1 sls (<72 hr.}?
yes-
N/A.
3.
Rush Turn ArdiMd Time Requested?
Oyes
16Nd -..
[]N/A
4,
Sufficient Vo14in.
yss
❑No
N/k
S.
_.__ ..
Correct Containers Used?
-PacB;Containers Used?
Yes
Yes
�Ato
No:
QNf+t
N/A
6:
Containers
Jte,,
a
N/,A .
7.
Dissolved analysfsrSamplgs field filtered?
QYes
Ne
kA
8..
Sample Ubels`Match COC?
-includes Date/TiMe/ID/Analysis Matrix:
MYes
W
QNo:
QN/A
9
Heads oce in VOA Vials >5.6in,m)?
Yes
EINQ
. Nix
io
Trip Blank Present?
Trip Blank Custody -Seals ?'resent?
(]yes
Qyes
©NG.
EJNo,=
♦rAW
NEA;
S2.
COMMENTS/SAMPLE
Cot ID of split egntaina-i
CLIENT NOTIMATION/RE50t U'ftQN
Person contacted:
Project Manager SCURF Review:
p'rwa ltdamageaRFAeview:.
ream uata rtequirea7 Uses. UNo
(late/Time:
Date:
Page 5 of 13
Qualtrax ID: 69614 Page 1 of 2

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BP3U 2SO mLPlasticUnpreserved (N/A)
BPZU-500 mL Plastic Unpreserved (N/A)
BP1U-111ter Plastic Unpreserved (N/A)
BM425 ml- Plastic H2504 (pH < 2) (Cl-)
OPSN-250 mL plastic HNO3 (pH < 2)
BP4L-12S ml Plastic ZN Acetate & NaOH (>9)
BP45-125,mL Plastic NaOH (pH > 12) (CI-)
WGFU-Wide-mouthed Glass jar Unpreserved
7-17
AGIU-1 liter Amber Unpreserved (N/A) (CO-)
zzzzzzzAG11-1-1
liter Amber HCl (pH < 2)
AG31.1-250 mL Amber Unpreserved (N/A) (CI-)
AG15-1 liter Amber H2SO4 (pH 4 2)
AG35-250 mL AmberR2SO4 (pH < 2)
DG94-250 mL Amber NH4CI (N/A)(CI-)
DG91i-40 mL VOA HCI (N/A)
VG9T-40 ml VOA Na25203 (N/A)
V69U40 mL VOA Unpreserved (N/A)
DG9V-40 ml. VOA H3PO4 (N/A)
O695-40 ml VOA H2SO4 (N/A)
V/GK (3 vials per kit)-VPH/Gas kit (N/A)
SPST-125 mL Sterile Plastic (N/A — lab)
SP2T-250 ml Sterile Plastic (N/A — lab)
zz
BP3R-250,mL Plastic(NH2)2SO4 (93-9.7)
AGOU-100mL Amber Unpreserved (N/A) (Q-)
VSGU-20mL Scintillation vials (N/A)
DG9U-40 MLAmber Unpreserved vials (N/A)
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Bioassay Chair? of Custody Form
5I,e1b .
z Faclli Name:
Addre s� fir, �,, S+ Ro. BOX.,
�� f a • gy -6885
r b Ai'G l $ Se Phone # : _-,(-.�Li
Contact:
NPDES permit #:
A a 2 /9 pipe: o 10
County :
Plant Plovr:
Efflu nt Dilution
Select est Method: 600A PFPpr
a000PFCNC P.pranetas PasatFall Acute 600A FRppr
C. dubla PasslFall Chrnnfo g00C FRCN ❑ P.p�as Full Range Acute
C. dubla Full Range Chronic Chror>tc 621C FRPpr
600A Pl Cdu ❑ P,pmmelas lull Rare
[] C, dubla PasOail gcufe 600A PFMtia
j] M. bahta Pasa/1'stl Aarte /
Sample Ilectoc Print
Signature
Grab
Sample
Co
lime: ��AM or PM
ite Started AM or PM
Ife Ended ------ _ Time: � .
Imples per Hr. #
Date: �
t Z Time: �Qor PM
�( 11 � Z a ' .
Volume:. Chilled during GailedOh?
heln of Gustod Rot
cease
L
Yes or No
Date Time
Pace Wank rdar Numt�er. Received Ey:
Recervin Temperature:-i------
cat Services, Mc Address: 6701 Corfiemnce Ix., RaSefgh, NG 27807 Phone: (9i8)834 �84

r
5bdl7 NC Lab Cert: 238
City of Shelby NPDES: NC 0024538
- AMMONIA, 4500-NH3 D-2011
DATE/ANALYST: _.1 - Meter: Metrohm 781, sn 1781001011201
Calibration with: mL of NaOH pH > 11s.u. Calibration Slope (-54-60 mV): — j $ • `(
Std 0.50 m L NH3-N 00 ✓ Effluent C12 Check (<O.S mg/L) :
Std 5.0 m L NH3-N • 4xi ✓ Effluent w/H2SO4, <2 pH s.u.: ✓
Std S0.0 mg/L NH3-N I I-00I Influent w/H2SO4, <2 pH s.u. :
Sample ID
mL of NaOH*
pH > 11s.u.
mL Sample
Dilution Factor
Concentration
m L
Report result
NH3-N m L)
Blank
l- arl
U/
po
, Oka
Method Blank
(- wl
✓
- 6V
010
CVS Std 25.0 m L NH3-N
i oa
t✓
Z;_0
—.0
LCS 5 m L NH3-N
°O
✓
�`�
Effluent- Compliance
Influent- Compliance
04
WTP Lagoon- Compliance
`(•
1.03
DO
Primary Cl. Eff-P. Control
1-7• G
'� 6
.Secondary- P.Control
(_p�
`�
.16
6.
Filtrate- P. Control
3
�✓
I Q
�').
MS 5m L NH3-N LCS
1.60
✓
.5 to 100
JMS
Duplicate
( •0rj
✓
.5 to 100
�%- t{
r , Ll
CVS
Std 25.0 m L NH3-N
(.60
too
I `
BLANK
END
1..o
(00
0.090
IN q0
pH checked with pH paper: ✓ QC Criteria: CVS ± 10%
samples at room temperature: ✓ Duplicates ± 15%
NaOH Lot # 4202664 Second Source ± 1S%
NH3-N Std Lot # AVl #2 MS ± 1S%
Second Source (LCS) Lot # AV1 #1
Date Stds Made: 2/27/2023
D z'1 T(7t-
Idili J 71
Document#: WWT-3001.023A�E� 'n
n�12
Effective Date:6/11/19 pZ—.2 ( -Z?
*Dilution Calc is used if NaOH differs
between sample and standard:
DIIUtIOn CaIC. = 100+Na0H added to sample
100+NaOH added to standard
Corresponding Procedure:
WWr-3000.023

Shelby
--.,
Start Time:
City of Shelby NPDES: NC 0024538
NC Lab Certification: 238
Biochemical Oxygen Demand SM 5210 B-2016
Hach Meter and Probe, SN 180403039023
Date: Mon 2/20/2023
Sample
Description
Bottle
#
6.0-8.0
(su)
pH*
mL
Sample
mL Seed
Init. DO
(mg/L)
5 Day
DO
(mg/L)
Amt. 02
Seed
Corr.
Corr.
DO
(mg/L)
BOD
(mg/L)
BOD Report
Blank
0
0
a
Blank]
0
0
g .
Seed Blank
0
4.5
Seed Control 7
0
15
Seed Control. t
0
20
GGA E
6
4.5
n
c{,(�
t{{}L`,-ISJ
J
GGA dq0
6
4.5
LJ.a�
y.05
l,b'
�(
�j�,
GGA P
6
4.5
Influent I
,Influent
4
6
4.5
4.5
Influent 30
8
4.5
Effluent 'A
Effluent 3
Effluent S
190
190
200
4.5
4.5
4.5
S b
Z I
S rJ
5,''
q
a
('0
.0�
q
4-
3
(�
I
- -( �1
1
Pri. Cl. Eff
10
4:5-
Day 0
Day 5
Bottle # (:N 16,1
Drift Chk Start 5
u-2�
Drift Chk Mid
Drift Chk End
*If pH adjustment or sodium sulfite Date/Time Collect: <48 hrs
titration needed rer�ord on back Effluent
Cl2 Check ✓ v/ Influent- yr d0-.2 04Y
Sample Heated: 20 ± 3°C� Polyseed Lot #: 182210
Incubator: 20 ± 1°C GGA Lot A2134
Blank Average must be s 0.2 mg/L Nutrient Lot #: 22295
C= Compliance ----- PC = Process Control
Calibration Day 0 Time = &ZI
Temp("C)=, 0,�pmHG= 7'12-
DO(mg/L)= jT. DO= T j % error -
Calibration 7 S
Calibration Day 5 Time
Temp("C)=201mmHG=75(o I A,
DO(mg/L)=I.(& T. DO=% error-/-V/
Percent error = (DO / T. DO) x 100 I
Sh r-UP: COMPLETED: --Dilution water is made the day of analysis, by analyst, with
Day: Wednesday Day: Monday 12 L aged DI water and 2 vials of nutrient buffer.
Date: 2/22/2023 Date: 2/27/2023 -Polyseed prepared on _2 15 23 b Y P P // by —AG with 1
Time: �j"� Time: � polyseed capsule to 500 mL of prepared BOD Dilution water
Initials: Initials: I t1j per Polyseed instructions.
JV3
Document #: WWT-3001.001A
Effective Date: 8/25/21 Corresponding Procedure: WWT-3000.001

helb City of Shelby NPDES: NC 0024538
NC Lab Certification: 238
Biochemical Oxygen Demand SM 5210 B-2016
Start Time: 2 of r Hach Meter and Probe, SN 180403039023 Date: Tue 2/21/2023
Sample
Description
Bottle
#
6.0-8.0
(su)
pH`
mL
Sample
mL Seed
Init. DO
(mg/L)
5 Day
DO
(mg/L)
Amt. 0 z
Seed
Corr.
Corr.
DO
m L
( g/)
BOD
(mg/L)
BOD Report
Influent
1
4
4.5
Influent
1�b
6
4.5
S .1 i
I.0
5
Influent
u1
8
4.5
Effluent
180
4.5
Effluent
190
4.5
.L{
(,� (
(�, 3 r,
J _ q
Effluent
{
200
4.5
Pri. Cl. Eff
10
4.5
'
Lagoon Effluent
11
Z< .)
50
4.5
�y 3
l
(Q��
Lagoon Effluent
1 I
100
4.5SL?
Lagoon Effluent
H O
120
4.5
��
{ . j t
! �
� j 0
a, j
Lagoon Effluent
S >
180
4.5
J'
i
.��3
. (p
>< .
Lagoon Effluent
190
4.5
(C �6
t •�
i
Lagoon Effluent
200
4.5
tJek+t
L.o�•0 i
Day 0
Da 5
Bottle #
Drift Chk Start
44
Drift Chk Mid
Drift Chk End
`It pH adjustment or sodium sulfite Date/Time Collect: <48 hrs
titration needed - record on back Effluent
V
C12 Check Influent
Sample Heated: 20 + YC� Polyseed Lot #: 182210
Incubator: 20 ± 1 C GGA Lot A2134
Blank Average must be s 0.2 mg/L Nutrient Lot #: 22295
C= Compliance ----- PC = Process Control
Calibration Day 0 Time =
Temp(°C)= mmHG=
DO(mg/L)= T. DO % error=
Calib at{6f��/aylz Time =
Temp('C)= m G= I
DO(mg/L)= T. DO= % error=
Percent error = (DO / T. DO) x 100
SET-UP:
COMPLETED:
Dilution water is made the day of analysis, by analyst, with
Day:
Wednesday
Day: Monday
12 L aged DI water and 2 vials of nutrient buffer.
Date:
2/22 2023
Date: 2/27/2023
—Polyseed prepared on by with 1
Time:
/' J '
Time:
_2/15Z23 _AG_
polyseed capsule to 500 mL of prepared BOD Dilution water
Initials:
iF
Initials: d-�'i�
per Polyseed instructions. S —
lyJ
�I- Flo s��- � 1� �� dr � �-0r^s � L �o �.,J, 4.e,.� �, ��: d� .f- � l,ue � I-� a•5(L pc5,
7U- o ,t_ (IwW i,- 041- use c�ei� cr...=v �F s ore ,w(,,,.e . DJ,*,— i;
Document #: WWT-3001.001A AV`
Effective Date: 8/25/21 Corresponding Procedure: WWT-3000.001

;ac ie A na ly fica I
www.pacelabs.com
i
February 27, 2023
Mr. Billy Wilkie
City of Shelby WTP
PO Box 207
801 West Grover Street - 28150
Shelby, NC 28151
RE: Project: TOC 001/ COD 001
Pace Project No.: 92653398
Dear Mr. Wilkie:
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Enclosed are the analytical results for sample(s) received by the laboratory on February 22, 2023. 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
If you have any questions concerning this report, please feel free to contact me.
Sincerely,
Jonathan W Biddix
[e-mail]
[phone]
Project Manager
Enclosures
cc: Jamal Jolly, City of Shelby WTP
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services, LLC.
Page 1 of 11

;ac e A na ly fica / 6
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Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
CERTIFICATIONS
Project: TOC 001/ COD 001
Pace Project No.: 92653398
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 Virginia/VELAP Certification #: 460222
North Carolina Wastewater Certification #: 40
REPORT OF LABORATORY ANALYSIS
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without the written consent of Pace Analytical Services, LLC. Page 2 of 11

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SAMPLE ANALYTE COUNT
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Project: TOC 001/ COD 001
Pace Project No.: 92653398
Analytes
Lab ID Sample ID Method Analysts Reported Laboratory
92653398001 TOC 001 SM 531OB-2014 MJP 1 PASI-A
92653398002 COD 001 SM 5220D-2011 JMH1 1 PASI-A
PASI-A = Pace Analytical Services - Asheville
REPORT OF LABORATORY ANALYSIS
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ace Analytical
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ANALYTICAL RESULTS
Project: TOC 001/ COD 001
Pace Project No.: 92653398
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Sample: TOC 001 Lab ID: 92653398001 Collected: 02/21/23 10:45 Received: 02/22/23 07:50 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
5310B TOC Analytical Method: SM 531 OB-2014
Pace Analytical Services - Asheville
Total Organic Carbon ND mg/L 1.0 1 02/26/23 13:53 7440-44-0
Date: 02/27/2023 02:47 PM
REPORT OF LABORATORY ANALYSIS
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ANALYTICAL RESULTS
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Project: TOC 001/ COD 001
Pace Project No.: 92653398
Sample: COD 001 Lab ID: 92653398002 Collected: 02/21/23 10:46 Received: 02/22/23 07:50 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
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 02/24/23 11:09 02/24/23 16:28
REPORT OF LABORATORY ANALYSIS
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Date: 02/27/2023 02:47 PM without the written consent of Pace Analytical Services, LLC. Page 5 of 11

1�;a'ce Analytical
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QUALITY CONTROL DATA
Project: TOC 001/ COD 001
Pace Project No.: 92653398
QC Batch: 757961 Analysis Method: SM 5220D-2011
QC Batch Method: SM 5220D-2011 Analysis Description: 5220D COD
Laboratory: Pace Analytical Services - Asheville
Associated Lab Samples: 92653398002
METHOD BLANK: 3937403 Matrix: Water
Associated Lab Samples: 92653398002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Chemical Oxygen Demand mg/L ND 25.0 02/24/23 16:20
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
LABORATORY CONTROL SAMPLE: 3937404
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Chemical Oxygen Demand mg/L 750 760 101 90-110
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 3937405 3937406
MS MSD
92652538007 Spike Spike MS MSD MS MSD % Rec
Parameter Units Result Conc. Conc. Result Result % Rec % Rec Limits RPD Qual
Chemical Oxygen Demand mg/L 207000 100 100 314 314 107 107 90-110 0
ug/L
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 3937407 3937408
MS MSD
92652375001 Spike Spike MS MSD MS MSD % Rec
Parameter Units Result Conc. Conc. Result Result % Rec % Rec Limits RPD Qual
Chemical Oxygen Demand mg/L 35.8 100 100 150 148 114 112 90-110 2 J(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: 02/27/2023 02:47 PM without the written consent of Pace Analytical Services, LLC.
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1�;a'ceAnalytical'
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QUALITY CONTROL DATA
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Project: TOC 001/ COD 001
Pace Project No.: 92653398
QC Batch: 758167 Analysis Method: SM 531OB-2014
QC Batch Method: SM 531OB-2014 Analysis Description: 5310B TOC
Laboratory: Pace Analytical Services - Asheville
Associated Lab Samples: 92653398001
METHOD BLANK: 3938378 Matrix: Water
Associated Lab Samples: 92653398001
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Organic Carbon mg/L ND 1.0 02/26/23 13:16
LABORATORY CONTROL SAMPLE: 3938379
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Total Organic Carbon mg/L 25 23.5 94 90-110
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 3938380 3938381
MS MSD
92653398001 Spike Spike MS MSD MS MSD % Rec
Parameter Units Result Conc. Conc. Result Result % Rec % Rec Limits RPD Qual
Total Organic Carbon mg/L ND 25 25 24.1 24.5 93 95 90-110 1
Results presented on this page are in the units indicated by the "Units' column except where an attemate unit is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 02/27/2023 02:47 PM without the written consent of Pace Analytical Services, LLC.
Page 7 of 11

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I
QUALIFIERS
Project: TOC 001/ COD 001
Pace Project No.: 92653398
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
MDL - Adjusted Method Detection Limit.
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[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
J(M1) Estimated Value. 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: 02/27/2023 02:47 PM without the written consent of Pace Analytical Services, LLC. Page 8 of 11

1�;a'ceAnalytical'
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QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: TOC 001/ COD 001
Pace Project No.: 92653398
Pace Analytical Services, LLC
2225 Riverside Dr.
Asheville, NC 28804
[phone]
Analytical
Lab ID Sample ID QC Batch Method QC Batch Analytical Method Batch
92653398002 COD 001 SM 5220D-2011 757961 SM 5220D-2011 758060
92653398001 TOC 001 SM 531OB-2014 758167
Date: 02/27/2023 02:47 PM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Page 9 of 11

CHAIN -OF -CUSTODY Analytical Request Document
WO## : 92653398
-IstPaceWOrkorderNumberor
aceAnalytical
`e �_
Chain -of
Custody is a LEGAL DOCUMENT - Complete all relevent fields
IIIIII
1111111111111111
o
Company:City of Shelby WTP
Billing Information:
AB USE ONLY m
92653398
Address:801 W Grover st Shelby NC
IOject Manager: 0
Report To: Billy Wilkie
I
Email To: b[[e-mail]
$- Preservative Types: (1) nitric acid, (2) sulfuric acid, (3) hydrochloric
acid, (4) sodium hydroxide, (5) zinc acetate,
(6) methanol, (7) sodium bisulfate, (9) sodium thiosulfate, (9) hexane, (A) ascorbic acid, (B) ammonium sulfate,
Copy To:
Site Collection Info/Address:
(C) ammonium hydroxide, (D) TSP, (U) Unpreserved, (0) Other
801 w Grover st Shelby NC 28150
Analyses
Lab Profile/Line:
Customer Project Name/Number:
State: County/City: Time Zone Collected:
Lab Sample Receipt Checktilst:
Nc /Cleveland
[ ]PT[ ]MT[ JCT ET
Custody Seals Present/SnlraCt Y N NA
Phone:[phone]
ite/Facility ID #
Compliance Monitoring?
Custody Signatures Present Y N YTIA
Email:
CO0271
7 /
( J Yes VNO
Collector Signature Ptessnt Y N NA
Bottles Intact Y N NA
Collected By (print):
urchase Order
DW PWS ID p:
Correct Bottles y N NA
uote fJ:
DW Location Code:
Sufficient volume Y N NA
Collected By (signature):
urnaround Dat
Required:
Immediately Packed an ice:
Samples Received on Ice Y N NA
VOA - Headspace Acceptable Y N NA
] Yes [ ] No
USDA R—julatad Soils Y N NA
Samples in Holding Time Y N NA
Sample Disposals
ush:
Field Filtered (if applicable):
P—idual chlorinn Fx waant Y N NA
I I Dispose as appropriate I I Return
[ J Sam
R Day [ J Next Day
( ] Yes [ )No
Cl Strips:
( I Archive:
[ ] 2 Day (
3 Day [ ] 4 Day [ ] 5 Day
Analysis:
Sample p6 Acceptable Y N NA
pH Strips:
[ J Hold:
(Ex
dite Charges Apply)
_ _ - --
Sulfide Present Y N NA
Matrix Codes (Insert in Matrix box
elow): Drinkinig
Water (DW), Ground Water (GW), Wastewater (WW),
Lead Acetate Stl Ips:
Product (P), Soil/Solid (SL), Oil (OQJI Wipe (WP), Aiij
(AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT)
LAB USE ONLY:
j
Comp /
Collected (or
Res
# of
0
Lab Sample 1 / Ccmment:r:
Customer Sample ID
Matrix "
Grab
Composite Start)
Composite End
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Time
Date
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Customer Remarks / Special
Relinquished by/Company:
/ Possible H zards: Type of Ice Used: . Wet Blue Dry None
Packing Material Used..—
Radchem sample(s) screened (<500 cpm): Y N NA
Date/Time: Received Si tur
Z 47,-Z3 0If
Date/Time: Received by/Company: (Signature)
Date, Time: Received by/Company: (Signature)
SHORT HOLDS PRESENT (<72 hours): Y N N/A
Lab Tracking #:
Samples received via:
FEDEX UPS Client Courier Pace Courier
Date/Time: MTJL LAB USE ONLY
Table #:
Lab Sample Temperature Info:
Temp Blank Received: Y N NA
Therm ID#: I
Cooler 1 Temp Upon Receipt: _oC
Cooler 1 Therm Corr. Factor: oC
Cooler 1 Corrected Temp: oC
Comments:
�a �r Template: Trip Blank Received: Y N NA
Prelogin: HCL McOH TSP Other
Date/Time: PM:
Non Conformance(s): Page:
PB: YES / NO I of:

'Pace ,----- vv f valll IC VVrlultiull V JU11 Recelpt
Effective Date: 05/12/202205/12/2022
"Check mark top half of box if pH and/or dechlorination is verified and Project # 9265
within the acceptance range for preservation samples. . PM: JW8 3398
Exceptions: VOA, Coli►orm, TOC, Oil and Grease, oRo/8015 (water) oOC, Ll►sg CLIt: 83_She`b Due Date. 0$/ 23
NT: 08/
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sample ID Type of Preservative pH upon receipt Date preservation adjusted Time preservllion Amount of Preservative Lot f1
adjusted added
Voter-WhrrtevertlTemJrTdiscrepancy affecting NoriFCarolina compliance samples, a copy of this form will be sent talhe North Carolina DENR Certification Office (i.e.
Out of hold, incorrect preservative, out of temp, incorrect containers.
Quallrax IQ: 69614 Page 2 of 2 Page 11 of 11

Jan 2022 Feb 2022 Mar 2022 Apr 2022 May 2022 Jun 2022 Jul 2022 Aug 2022 Sep 2022 Oct 2022 Nov 2022 Dec 2022
Date
27
2s
2s
30
31

NPDES Renewal Table C Fluoride, Nitrogen, Phosphorus, Aluminum
Jan 2022
Lagoons Fluoride
1001
Lagoons
Lagoon - Total Nitrogen Lagoon - Total Phosphorus
U.5001 0.050
Lagoons Aluminum
250
Feb 2022
Mar 2022
Apr 2022
100
0 580
0 050
168
May 2022
Jun 2022
Jul 2022
130
0.430
0.050
228
Aug 2022
Sep 2022
Oct 2022
100
0.580
0 050
239
Nov 2022
Dec 2022
Minimum
100
0.430
0.050
168
Maximum
130
0 580
0.050
250
Total
4301
2.0901
0.200
885
Average
108
0.523
0 050
221

City of Shelby
Shelby WTP
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