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HomeMy WebLinkAboutNCG030697_2024 DMR_20240327 GR Geological Resources, Inc. March 27, 2024 Mr. Jerry Eplin Land Quality Division Division of Energy, Mineral, and Land Resources North Carolina Department of Environmental Quality Mooresville Regional Office 610 E. Center Ave. Suite 301 Mooresville, North Carolina 28115 RE: Discharge Monitoring Report—January-March 2024 ITEC— Monroe Facility 2402 Walkup Avenue Monroe, Union County, North Carolina General NPDES Permit# NCG030000 Certificate of Coverage # NCG030697 GRI Project# 6092 Dear Mr. Eplin: On behalf of Instrument Transformer Equipment Corporation (ITEC) — Monroe Facility, please find attached results of stormwater outfall sampling that was conducted on January 9, 2024, for the ITEC facility in Monroe, Union County, North Carolina. Water samples were collected from the outfall SDO-1 by ITEC personnel on January 9, 2024, in accordance with the sampling requirements of the permit. Water samples were analyzed for total suspended solids (TSS), non-polar oil and grease, pH, chemical oxygen demand (COD), and total recoverable lead, copper, and zinc. The January 2024 sampling results indicated that there were no exceedances of TSS, non-polar oil and grease, pH, COD, or total recoverable lead, copper, or zinc in the sampled outfall. The Stormwater Discharge Outfall Monitoring Report is included in Appendix A, the Stormwater Discharge Outfall Qualitative Monitoring Report is included in Appendix B, and a complete laboratory analytical report is included as Appendix C. 3502 Hayes Road • Monroe, North Carolina 28110 113 West Firetower Road, Suite G • Winterville, North Carolina 28590 Phone (704) 845-4010 • (888) 870-4133 • Fax (704) 845-4012 Discharge Monitoring Report—January-March 2024 ITEC—Monroe Facility Monroe, Union County, North Carolina Certificate of Coverage# NCG030697 Page 2 of 2 The next semi-annual sampling event is scheduled to be conducted between April through June 2024 during a representative rainfall event. Please do not hesitate to contact me at (704)845-4010, if you have any questions or comments. Sincerely, Eric M. Eubanks, P.G. Project Manager cc: Mr. Kirk Schaeffer, Group ITEC, LLC Division of Water Resources Central Files, NCDEQ, 1617 Mail Service Center, Raleigh, NC 27699-1617 file enclosures 3502 Hayes Road • Monroe, North Carolina 28110 113 West Firetower Road, Suite G • Winterville, North Carolina 28590 Phone (704) 845-4010 • (888) 870-4133 • Fax (704) 845-4012 APPENDICES APPENDIX A STORMWATER DISCHARGE OUTFALL MONITORING REPORT NCDEQ Division of Energy,Mineral and Land Resources Stormwater Discharge Monitoring Report(DMR) Form for NCG030000 Metal Fabrication Click here for instructions Complete,sign,scan and submit the DMR via the Stormwater NPDES Permit Data Monitoring Report(DMR)Upload form within 30 days of receiving sampling results. Mail the original,signed hard copy of the DMR to the appropriate DEMLR Regional Office. Certificate of Coverage No. NCGO3 0697 Person Collecting Samples:Kirk Schaeffer Facility Name:ITEC-Monroe Facility Laboratory Name:Waypoint Analytical, Inc. Facility County:Union Laboratory Cert. No.:402 Discharge during this period:El Yes El No (if no,skip to signature and date) Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances?QYes Q No If so,which Tier(I,II,or Ill)? A copy of this DMR has been uploaded electronically via https://edocs.deq.nc.gov/Forms/SW-DMR El Yes Jj No Date Uploaded: Analytical Monitoring Requirements for Outfalls with Industrial Activities—Benchmarks in(Red) Parameter Code Parameter Outfall SDO-1 Outfall Outfall Outfall Outfall N/A Receiving Stream Class C N/A Date Sample Collected MM/DD/YYYY 01/09/2024 46529 24-Hour Rainfall in inches 2.22 C0530 TSS in mg/L(100 or 50*) 19.9 00400 pH in standard units(6.0—9.0 FW, 6.6 H 6.b-a.s Jw) 01119 Copper,total recoverable in mg/L (0.010 FW,0.0058 SW) 0.0100 01051 Lead,total recoverable in mg/L 0.0051 J (0.075 FW,0.22 SW) 01094 Zinc,total recoverable in mg/L(0.126 FW,0.095 SW) 0.0056 J 00340 Chemical Oxygen Demand(COD)in 43 mg/L(120) 00552 Non-Polar Oil&Grease in mg/L <2.2 Outfalls to Outstanding Resource Waters(ORW),High Quality Waters(HQW),Trout Waters(Tr)and Primary Nursery Areas(PNA) have a benchmark TSS limit of .All other water classifications have a benchmark of (Freshwater) (Saltwater) Notes(optional): "I certify by my signature below,under penalty of law,that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted.Based on my inquiry of the person or persons who manage the system,or those persons directly responsible for gathering the information,the information submitted is,to the best of my knowledge and belief,true,accurate,and complete.I am aware that there are significant penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations." 02/15/2024 'Signature of Perrhittee or Delegated Authorized Individual Date kschaeffer@itec-ctvt.com (704)266-8135 Email Address Phone Number APPENDIX B STORMWATER DISCHARGE OUTFALL QUALITATIVE MONITORING REPORT • Environmental Quality Stormwater Discharge Outfall (SDO) Qualitative Monitoring Report For guidance on filling out this form,please visit https://deq.nc.gov/about/divisions/energy-mineral-land-resources/ npdes-stormwater-gps Permit No.: N/C/ / / / / / / / or Certificate of Coverage No.: N/C/G/0/3/0/6/9 /7 / Facility Name: INSTRUMENT TRANSFORMER EQUIPMENT CORPORATION (ITEC)-MONROE FACILITY County: UNION !! Phone No. (704)266-8135 Inspector: l{ i t/' Sc hQ P f-it f Date of Inspection: I j q ) z a Z Time of Inspection: I-l'/d Total Event Precipitation(inches): All permits require qualitative monitoring to be performed during a"measurable storm event." A"measurable storm event"is a storm event that results in an actual discharge from the permitted site outfall. The previous measurable storm event must have been at least 72 hours prior. The 72-hour storm interval does not apply if the permittee is able to document that a shorter interval is representative for local storm events during the sampling period,and the permittee obtains approval from the local DEMLR Regional Office. By this signature,I certify that this report is accurate and complete to the best of my knowledge: (Signature of Permittee or Designee) 1. Outfall Description: Outfall No. SDO-1 Structure(pipe,ditch,etc.): OUTFALL OF POND#1-DISCHARGE PIPE Receiving Stream: RICHARDSON CREEK Describe the industrial activities that occur within the outfall drainage area: '7`►2 ae-cfz)s.vc- iVk4'ill 4. ✓✓r pe 1/ 11f4-Lc '-i- Cr c { ii i K l to f l cc c, �red tar Page 1 of 2 SWU-242,Last modified 06/01/2018 2. Color: Describe the color of the discharge using basic colors(red,brown,blue,etc.)and tint (light,medium, dark)as descriptors: c i G,; 13 (e`} h 3. Odor: Describe any distinct odors that the discharge may have(i.e.,smells strongly of oil,weak chlorine odor,etc.): A)I) 4. Clarity: Choose the number which best describes the clarity of the discharge,where 1 is clear and 5 is very cloudy: 2 3 4 5 5. Floating Solids: Choose the number which best describes the amount of floating solids in the stormwater discharge,where 1 is no solids and 5 is the surface covered with floating solids: 1 2 3 4 5 6. Suspended Solids: Choose the number which best describes the amount of suspended solids in the stormwater discharge,where 1 is no solids and 5 is extremely muddy: 1 (2 ) 3 4 5 7. Is there any foam in the stormwater discharge? 0 Yes No. 8. Is there an oil sheen in the stormwater discharge? 0Yes X No. 9. Is there evidence of erosion or deposition at the outfall? 0 Yes 56 No. 10. Other Obvious Indicators of Stormwater Pollution: List and describe Aid y 1v J s (.- At c Note: Low clarity,high solids,and/or the presence of foam,oil sheen,or erosion/deposition may be indicative of pollutant exposure. These conditions warrant further investigation. Page 2 of 2 SWU-242,Last modified 06/01/2018 APPENDIX C LABORATORY ANALYTICAL REPORT w° Waypoint 449 Springbrook Rd, Charlotte, NC 28217 Main 704.529.6364 ANALYTICAL www.waypointanalytical.com 1/29/2024 Geological Resources, Inc. Eric Eubanks 3502 Hayes Road Monroe, NC, 28110 Ref: Analytical Testing Lab Report Number: 24-012-0006 Client Project Description: ITEC- Monroe GRI #6092 Dear Eric Eubanks: Waypoint Analytical, LLC (Charlotte) received sample(s) on 1/11/2024 for the analyses presented in the following report. The above referenced project has been analyzed per your instructions. The analyses were performed in accordance with the applicable analytical method. The analytical data has been validated using standard quality control measures performed as required by the analytical method. Quality Assurance, method validations, instrumentation maintenance and calibration for all parameters were performed in accordance with guidelines established by the USEPA(including 40 CFR 136 Method Update Rule May 2021) unless otherwise indicated. Certain parameters (chlorine, pH, dissolved oxygen, sulfite...) are required to be analyzed within 15 minutes of sampling. Usually, but not always, any field parameter analyzed at the laboratory is outside of this holding time. Refer to sample analysis time for confirmation of holding time compliance. The results are shown on the attached Report of Analysis(s). Results for solid matrices are reported on an as- received basis unless otherwise indicated. This report shall not be reproduced except in full and relates only to the samples included in this report. Please do not hesitate to contact me or client services if you have any questions or need additional information. Sincerely, Danyale Love Project Manager Laboratory's liability in any claim relating to analyses performed shall be limited to, at laboratory's option, repeating the analysis in question at laboratory's expense, or the refund of the charges paid for performance of said analysis. Page 1 of 13 w VVáypoint 449 Springbrook Rd, Charlotte, NC 28217 Main 704.529.6364 ANALYTICAL www.waypointanalytical.com Certification Summary Laboratory ID: WP CNC: Waypoint Analytical Carolina, Inc. (C), Charlotte, NC State Program Lab ID Expiration Date North Carolina State Program 37735 07/31/2024 North Carolina State Program 402 12/31/2024 South Carolina State Program 99012 07/31/2024 South Carolina State Program 99012 12/31/2023 Page 1 of 1 00016/24-012-0006 Page 2 of 13 wo V\layP0I tit 449 Springbrook Rd, Charlotte, NC 28217 Main 704.529.6364 ANALYTICAL www.waypointanalytical.com Sample Summary Table Report Number: 24-012-0006 Client Project Description: ITEC - Monroe GRI #6092 Lab No Client Sample ID Matrix Date Collected Date Received 93936 Pond #1-Outfall Aqueous 01/09/2024 15:10 01/11/2024 16:32 Page 3 of 13 wo YY I\(aioint 449 Springbrook Rd, Charlotte, NC 28217 Main 704.529.6364 ANALYTICAL www.waypointanalytical.com Summary of Detected Analytes Project: ITEC - Monroe Report Number: 24-012-0006 Client Sample ID Lab Sample ID Method Parameters Result Units Report Limit Analyzed Qualifiers Pond#1 -Outfall V 93936 2540D-2015 Total Suspended Solids 19.9 mg/L 0.8 01/15/2024 10:20 4500H+B-2011 pH 6.6 s.u. 01/15/2024 10:15 5220D-2011 COD(Chemical Oxygen Demand) 43 mg/L 15 01/15/2024 14:10 EPA-200.7 Copper 0.0100 mg/L 0.0020 01/28/2024 17:44 EPA-200.7 Lead 5.10 pq/L 2.40 01/21/2024 02:25 J EPA-200.7 Zinc 0.0056 mg/L 0.0050 01/22/2024 21:19 J Page 4 of 13 Waypoint 449 Springbrook Rd, Charlotte, NC 28217 Main 704.529.6364 ANALYTICAL www.waypointanalytical.com Client: Geological Resources, Inc. CASE NARRATIVE Project: ITEC - Monroe Lab Report Number: 24-012-0006 Date: 1/29/2024 Oil and Grease -TPH Method 1664B-SGT Sample 93936 (Pond #1 - Outfall) QC Batch No: V42489 The result for the total Oil and Grease (HEM) analysis was less than the detection limit, meaning the SGT-HEM portion of the analysis is not required. All quality control associated with the total Oil and Grease procedure met the acceptance criteria. Total Metals Method EPA-200.7 Analyte: Lead QC Batch No: V42738/V42334 IPC/CCV failed high. Sample concentration BRL. Result not affected. Page 5 of 13 to Waypoi lWaypoint, 449 Springbrook Rd, Charlotte, NC 28217 Main 704.529.6364 ANALYTICAL www.waypointanalytical.com 00087 Geological Resources,Inc. Project ITEC-Monroe Eric Eubanks Report Date : 01/29/2024 3502 Hayes Road Information : GRI#6092 Received :01/11/2024 Monroe, NC 28110 Report Number :24-012-0006 REPORT OF ANALYSIS Danyale Love Project Manager Lab No : 93936 Matrix: Aqueous Sample ID : Pond#1-Outfall Sampled: 1/9/2024 15:10 Test Results Units MDL MQL DF Date/Time By Analytical Analyzed Method COD(Chemical Oxygen Demand) 43 mg/L 15 30 1 01/15/24 14:10 SLO 5220D-2011 SGT HEM: Non-Polar Material <2.2 mg/L 2.2 5.9 1 01/24/24 14:00 RLW 1664B-SGT pH 6.6 H s.u. 1 01/15/24 10:15 JMD 4500H+B-2011 Total Suspended Solids 19.9 mg/L 0.8 3.2 1 01/15/24 10:20 JMD 2540D-2015 Copper 0.0100 mg/L 0.0020 0.0050 1 01/28/24 17:44 JKC EPA-200.7 Lead 5.10 J la9/L 2.40 6.00 1 01/21/24 02:25 JKC EPA-200.7 Zinc 0.0056 J mg/L 0.0050 0.0100 1 01/22/24 21:19 JKC EPA-200.7 Qualifiers/ DF Dilution Factor H Beyond holding time Definitions J Estimated value MQL Method Quantitation Limit Page 6 of 13 o \fv'aypoint 449 Springbrook Rd, Charlotte, NC 28217 Main 704.529.6364 ANALYTICAL www.waypointanalytical.com Quality Control Data Client ID: Geological Resources,Inc. Project Description: ITEC- Monroe Report No: 24-012-0006 QC Analytical Batch: V42489 Analysis Method: 1664B-SGT Analysis Description: Oil and Grease-TPH Lab Reagent Blank LRB Matrix: AQU Associated Lab Samples: 93936 Blank MDL MQL Analyzed Parameter Units Result SGT HEM: Non-Polar Material mg/L <1.9 1.9 5.0 01/24/24 14:00 Ongoing Precision and Recovery OPR Spike OPR % Analyzed %Rec Qualifie Parameter Units Conc. Result Recovery Limits SGT HEM: Non-Polar Material mg/L 20.0 18.0 90.0 01/24/24 14:00 64-132 Date: 01/29/2024 01:37 PM Page 1 of 5 Page 7 of 13 o V /aypoint 449 Springbrook Rd, Charlotte, NC 28217 Main 704.529.6364 ANALYTICAL www.waypointanalytical.com Quality Control Data Client ID: Geological Resources,Inc. Project Description: ITEC- Monroe Report No: 24-012-0006 QC Analytical Batch: V42283 Analysis Method: 2540D-2015 Analysis Description: Total Suspended Solids Lab Reagent Blank LRB Matrix: AQU Associated Lab Samples: 93936 Blank MDL MQL Analyzed Parameter Units Result Total Suspended Solids mg/L <0.7 0.7 2.5 01/15/24 10:20 Laboratory Control Sample LCS Spike LCS LCS%Rec %Rec Parameter Units Conc. Result Limits Total Suspended Solids mg/L 477 487 102 90-110 Duplicate V 93819-DUP Result DUP RPD Max RPD Analyzed Parameter Units Result Total Suspended Solids mg/L 4270 4070 4.7 10.0 01/15/24 10:20 Date: 01/29/2024 01:37 PM Page 2 of 5 Page 8 of 13 o \fv'aypoint 449 Springbrook Rd, Charlotte, NC 28217 Main 704.529.6364 ANALYTICAL www.waypointanalytical.com Quality Control Data Client ID: Geological Resources,Inc. Project Description: ITEC- Monroe Report No: 24-012-0006 QC Analytical Batch: V42318 Analysis Method: 4500H+B-2011 Analysis Description: pH Laboratory Control Sample LCS Spike LCS LCS%Rec %Rec Parameter Units Conc. Result Limits pH s.u. 6.8 6.8 100 3.54-101.z Laboratory Control Sample LCS21 Spike LCS LCS%Rec %Rec Parameter Units Conc. Result Limits pH s.u. 6.8 6.8 100 3.54-101.z Duplicate V 93936-DUP Result DUP Criteria Analyzed Parameter Units Result pH s.u. 6.6 6.6 +/-0.1 01/15/24 10:15 Date: 01/29/2024 01:37 PM Page 3 of 5 Page 9 of 13 o V /aypoint 449 Springbrook Rd, Charlotte, NC 28217 Main 704.529.6364 ANALYTICAL www.waypointanalytical.com Quality Control Data Client ID: Geological Resources,Inc. Project Description: ITEC- Monroe Report No: 24-012-0006 QC Analytical Batch: V42319 Analysis Method: 5220D-2011 Analysis Description: Chemical Oxygen Demand(COD) Lab Reagent Blank LRB Matrix: AQU Associated Lab Samples: 93936 Blank MDL MQL Analyzed Parameter Units Result COD(Chemical Oxygen Demand) mg/L <15 15 30 01/15/24 14:10 Laboratory Control Sample LCS Spike LCS LCS%Rec %Rec Parameter Units Conc. Result Limits COD(Chemical Oxygen Demand) mg/L 50 46 92.0 90-110 Matrix Spike&Matrix Spike Duplicate V 93626-MS V 93626-MSD MS Spike MSD MS Result MSD MS MSD %Rec Max Parameter Units Result Conc. Spike Result %Rec %Rec Limits RPD RPD Conc. COD(Chemical Oxygen Demand) mg/L < 15 50 50 55 56 110 112 80-120 1.8 20 Date: 01/29/2024 01:37 PM Page 4 of 5 Page 10 of 13 wo V/aypoint 449 Springbrook Rd, Charlotte, NC 28217 Main 704.529.6364 ANALYTICAL www.waypointanalytical.com Quality Control Data Client ID: Geological Resources,Inc. Project Description: ITEC- Monroe Report No: 24-012-0006 QC Prep: V42334 QC Analytical Batch(es): V42602,V42646,V42877 QC Prep Batch Method: EPA-200.7(PREP) Analysis Method: EPA-200.7 Analysis Description: Total Metals Lab Reagent Blank LRB-V42334 Matrix: AQU Associated Lab Samples: 93936 Blank MDL MQL Analyzed Parameter Units Result Copper pg/L <2.00 2.00 5.00 01/28/24 17:35 Lead pg/L <2.40 2.40 6.00 01/21/24 02:17 Zinc pg/L <5.00 5.00 10.0 01/22/24 21:10 Laboratory Control Sample LCS-V42334 Spike LCS LCS%Rec %Rec Parameter Units Conc. Result Limits Copper pg/L 1000 1110 111 85-115 Lead pg/L 100 101 101 85-115 Zinc pg/L 1000 1040 104 85-115 Matrix Spike&Matrix Spike Duplicate V 94060-MS-V42334 V 94060-MSD-V42334 MS Spike MSD MS Result MSD MS MSD %Rec Max Parameter Units Result Conc. Spike Result %Rec %Rec Limits RPD RPD Conc. Copper pg/L 11.5 1000 1000 1030 1020 102 101 70-130 0.9 20 Lead pg/L 5.60 100 100 95.7 96.2 90.0 91.0 70-130 0.5 20 Zinc pg/L <5.00 1000 1000 818 780 82.0 78.0 70-130 4.7 20 Date: 01/29/2024 01:37 PM Page 5 of 5 Page 11 of 13 �o • Wapoint 449 Springbrook Rd,Charlotte, NC 28217 Main 704.529.6364 ANALYTICAL www.waypointanalytical.com Shipment Receipt Form Customer Number:00087 Customer Name: Geological Resources, Inc. Report Number: 24-012-0006 Shipping Method O Fed Ex 0 US Postal 0 Lab 0 Other : 0 UPS 0 Client 0 Courier Thermometer ID: IRT15 1.0C Shipping container/cooler uncompromised? # Yes 0 No Number of coolers/boxes received 1 Custody seals intact on shipping container/cooler? 0 Yes 0 No 0 Not Present Custody seals intact on sample bottles? 0 Yes 0 No 0 Not Present Chain of Custody (COC) present? 0 Yes 0 No COC agrees with sample label(s)? 0 Yes 0 No COC properly completed 0 Yes 0 No Samples in proper containers? 0 Yes 0 No Sample containers intact? 0 Yes 0 No Sufficient sample volume for indicated test(s)? 0 Yes 0 No All samples received within holding time? 0 Yes 0 No Cooler temperature in compliance? 0 Yes 0 No Cooler/Samples arrived at the laboratory on ice. 0 Yes 0 No Samples were considered acceptable as cooling process had begun. Water- Sample containers properly preserved 0 Yes 0 No 0 N/A Water- VOA vials free of headspace 0 Yes 0 No 0 N/A Trip Blanks received with VOAs 0 Yes 0 No 0 N/A Soil VOA method 5035—compliance criteria met 0 Yes 0 No 0 N/A High concentration container (48 hr) Low concentration EnCore samplers (48 hr) High concentration pre-weighed (methanol -14 d) Low conc pre-weighed vials (Sod Bis -14 d) Special precautions or instructions included? 0 Yes 0 No Comments: Signature: Angelo Norvell Date &Time: 01/12/2024 09:16:53 Page 12 of 13 SGS North America Inc - Orlando S G Chain of CustodyVinelandCSGS -ORLANDO JOB#: PAGE OF US Vineland Road.Suite -I S Orlando,Fl 32s l I TEL.407-125-6700 FAX:407-125-0707 SGS-ORLANDO Quote# SKIFF# s ws sp.corn I Client/Reporting Information 1 Project Information r Analytical Information Matrix Codes Company Name, ITEC MONROE Protect Name: U UW-Dunking ITEC- MONROE FACILITY 2 Water Address: Street N Q- cc GW-Ground 2402 WALKUP AVENUE 2402 WALKUP AVENUE Q W L) Water City: State: Zip: City State ct Q a Z WW•Water MONROE, NC 28110 LU ni SW-Surface MONROE NC 28110 O Project Contact: Email: ProjecttRl NO. 6092 (Contact: Rohit Shetty@GRI) ea °) y a CD Water KIRK SCHAEFFER kschaefferPitec-ctvt.com la SO-Soil Phone#: Fax 0 0 (9 a SL-Sludge (704) 266-8135 cc v a > of-OII Sampler(s)Name(s)(Fringe Client Purchase Order p p > LIO-Other Liquid Sampler 1:le✓K S,{1r, Ci-(rgampler2: GRI JOB No. 6092 0 v ou c4 AIR-Air COLLECTION CONTAINER INFORMATION tl SQL-Other Solid SGS & s vl Z —cc +-A TOrlando SAMPLED aOF a x w = 0 8 �' ; FN- 0 I Ou O '�-' FO- > < Sample Si Field ID/Point of Collection E.<-E TIME BY MATRIX BOTTLES ii Z i 2 I. 1 a I Z ~ I- LAB USE ONLY SDO-1 POND#1-OUTFALL Irti Al 15i Q KS SW 73. $ _ I 3 x x x X x x x m 0 - m _ H 1 5) 1 Nil IIII ppIp I � a. . IIIIIIIIIII ill IIIIII INA IIIII IIII Ill I I�Ii IIIII Will IIII IIII 000087zo Geological Resources.inc 24 ITEC-Monroe 09 1547 1 I I I I I I I Turnaround Time(Business days) Data Deliverable Information Comments I Remarks 10 Day(Busines_0. Approved By:I Date: LICOMMERCIAL"A"(RESULTS ONLY) 7 Day COMMERCIAL"B"(RESULTS PLUS QC) 5 Day EREDT1 (EPA LEVEL 3) 3 Day RUSH _ EFULLTI (EPA LEVEL 4) 2 Day RUSH ®EDD'S 1 Day RUSH - - - Other Rush T/A Data Available VIA Email or Lablink Sample Custody must be documented below each time samples change possession,including courier delivery. Relin uishe by Sampler/Affiliation Date Time: Recel ed 8y/Affiliatlow�' Rel�wgataned B �tl Date Time: Receiv By/Affiliation 1 .Da e Time: `/ /?-1'2 b y 3�i��-�' -� 1(11121 152 c a �i% . -- Re' fished by/Affiliation Date Time: ! Received By/ lotion Relinquished By/Affiliation �Dpt Time: Received By/Atfll n 5 ! `— „K/ 'A i/- CG 3�6 7 � r Z e 1 Lab Use Only: Cooler Temperature(s)Celsius(corrected): -(t S I. 0 - httD//www sgs com en/terms-and-Ondlhon5 1 ORLD-SMT-0001.03-FORM-COC(4)xIs Rev 031318