NC0020401_Inspection_20180718

s
Water Resources
Environmental Quality
19 July 2018
Mr. David Cox
Pretreatment Coordinator
City of Hickory
310 Cloninger Mill Road
Hickory, North Carolina 28601
Subject: Pretreatment Audit Inspection
City of Hickory
NPDES Permit No. NCO020401
Catawba County
Dear Mr. Cox:
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Interim Director
Enclosed is a copy of the Pretreatment Audit Inspection Report for the inspection of the City of
Hickory's Industrial Pretreatment Program on July 12, 2018, by Mr. Wes Bell of this Office.
Should you have any questions concerning this report, please do not hesitate to contact Mr. Bell
at [phone], or via email at [e-mail].
Sincerely,
EA
DocuSigned by:
41� H P
F161 FB69A2D84A3...
For W. Corey Basinger, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ
Enclosure:
Inspection Report
cc: Vivien Zhong, PERCS Unit ([e-mail])
State of North Carolina I Environmental Quality) Water Resources I Water Quality Regional Operations
Mooresville Regional Office 1610 East Center Avenue, Suite 310 1 Mooresville, North Carolina 28115
704-663-1699

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NORTH CAROLINA DIVISION OF WATER RESOURCES
PRETREATMENT AUDIT REPORT
Water Resources
ENVIRONMENTAL QUALITY
Background Information
1. Control Authority (POTW) Name: City of Hickory
2. Control Authority Representative(s): David Cox
3. Title(s): Pretreatment Coordinator
4. Address of POTW:
Mailing: 310 Cloninger Mill Road
City: Hickory Zip Code: 28601
Phone Number [phone] Ext. 204 Fax Number [phone] E -Mail dcox(a,hickorvnc.gov
5. Audit Date 07/12/2018
6. Last Inspection Date: 12/16/2016 Inspection Type: ® PCI ❑ Audit
7. Has Program Completed All Requirements from the Previous Inspection and Program Info Sheet(s)? ® Yes ❑ No
If No, Explain.
8. In the last year has the POTW experienced any NPDES or Sludge Permit compliance problems? ® Yes ❑ No
If Yes, Explain. Northeast WWTP - Weekly Average effluent TSS violation (April 2017) and pH daily minimum
violation (October 2017); Henry Fork WWTP — Chronic Toxicity failure (February 2018).
9. Is POTW under an Order That Includes Pretreatment Conditions? ❑ Yes ❑ No
Order Type and Number: Are Milestone Dates Being Met? ❑ Yes ❑ No ® NA
Parameters Covered Under Order
ICIS Coding
Main Program Permit Number
INIC1010I2 Io 14 to I1
MM/DD/YY
107 1 12 1 18
10.
....................................................................................................................................................................................................................................................................................................
Current Number of Significant Industrial Users (SIUs)?
14
11.
....................................................................................................................................................................................................................................................................................................
Number of SIUs with No IUP, or with an Expired IUP?
0
12.
....................................................................................................................................................................................................................................................................................................
Number of SIUs Not Inspected by POTW in Last Calendar Year?
0
13.
....................................................................................................................................................................................................................................................................................................
Number of SIUs Not Sampled by POTW in Last Calendar Year?
0
14.
..........................................................................
Number of SIUs in SNC for Limits Violations During Either of Last 2 Semi -Annual Periods?
..
1
15.
...................................................................................................
Number of SIUs in SNC for Reporting. During Either of Last 2 Semi -Annual Periods?
...................................................................................................................
0
16.
....................................................................................................................................................................................................................................................................................................
Number of SIUs in SNC with Pretreatment Schedule?
0
17.
....................................................................................................................................................................................................................................................................................................
Number of SIUs on Schedules?
0
18.
Current Number of Categorical Industrial Users (CIUs)?
0
19.
Number of CIUs in SNC?
0
NC DWR Pretreatment Audit Form Revised: December 2016
Page 1

20. PRETREATMENT PROGRAM ELEMENTS REVIEW:
Program Element
Northeast WWTP (NC0020401)
Last Submittal
Date In file?
Last Approval
Date In file
Date Next Due,
If Applicable
Headworks Analysis (HWA)
07/29/14
® Yes ❑ No
12/01/14
® Yes ❑ No
08/01/19
Industrial Waste Survey (IWS)
10/01/13
® Yes ❑ No
12/16/13
® Yes ❑ No
10/01/18
Sewer Use Ordinance (SUO)
09/20/12
® Yes ❑ No
10/22/12
® Yes ❑ No
Enforcement Response Plan (ERP)
05/30/18
® Yes ❑ No
06/07/18
® Yes ❑ No
Long Term Monitoring Plan (LTMP)
06/01/18
® Yes ❑ No
06/07/18
® Yes ❑ No
Program Element
Henry Fork WWTP (NC0040797)
Last Submittal
Date In file?
Last Approval
Date In file
Date Next Due,
If Applicable
Headworks Analysis (HWA)
03/29/18
® Yes ❑ No
06/07/18
® Yes ❑ No
04/1/23
Industrial Waste Survey (IWS)
10/01/13
® Yes ❑ No
12/16/13
® Yes ❑ No
10/01/18
Sewer Use Ordinance (SUO)
09/20/12
® Yes ❑ No
10/22/12
® Yes ❑ No
Enforcement Response Plan (ERP)
05/30/18
® Yes ❑ No
06/07/18
® Yes ❑ No
Long Term Monitoring Plan (LTMP)
06/20/18
® Yes ❑ No
07/03/18
® Yes ❑ No
Legal Authoritv (Sewer Use Ordinance-SUO
21. Do you have any towns and/or areas from which you receive wastewater which are not in your annexed jurisdiction?
® Yes ❑ No If yes, Please list these towns and/or areas. Hildebran, Longview, Brookford, and Catawba (Towns);
Alexander, Burke, and Caldwell Counties.
22. If yes to #21, Do you have current Interjurisdictional Agreements (IJAs) or other Contracts? ® Yes ❑ No ❑ NA
A copy, if not already submitted, should be sent to Division.
23. If yes to #21, Have you had any trouble working with these towns or districts? ❑ Yes ® No ❑ NA
If yes, Explain.
24. Date of Last SUO Adoption by Local Council 12/04/2012
25. Have you had any problems interpreting or enforcing any part of the SUO? ❑ Yes ❑ No
If yes, Explain.
Enforcement (Enforcement Response Plan -ERP)
26. Did you send a copy of the ERP to your industries? ® Yes ❑ No
If no, POTW must send copy within 30 days.
27. Have you had any problems interpreting or enforcing any part of the ERP (i.e. any adjudication, improper enforcement, etc?
❑ Yes ® No If yes, Explain.
28. List Industries under a Schedule or Order and Type of Schedule or Order. N/A
NC DWR Pretreatment Audit Form Revised: December 2016 Page 2

Resources
29. Please Rate the Following: S=Satisfactory M=Marginal U=Unsatisfactory
30. Does the POTW have an adequate data management system to run the pretreatment program? ® Yes ❑ No
Explain Yes or No. Excell
31. How does the POTW recover the cost of the Pretreatment Program from their industries? Explain.
Surcharges, penalties, SIU performs resampling for violations found during POTW sampling event.
Public Perception/ Participation
32. Are there any local issues affecting the pretreatment program (e.g.. odor, plant closing, new or proposed plants)?
❑ Yes ® No If yes, Explain.
33. Has any one from the public ever requested to review pretreatment program files? ❑ Yes ® No
If yes, Explain procedure. If no, how would the request be addressed? Written request would have to be submitted and
reviewed/approved by POTW's Attorney. Files would be reviewed at the Pretreatment Office under the supervision of
the Pretreatment Coordinator.
34. Has any industry ever requested that certain information remain confidential from the public? ® Yes ❑ No If yes, Explain
procedure for determining whether information qualified for confidential status, as well as procedure for keeping files confidential
from public. If no how would the request be addressed? Written request would have to be submitted and the documentation
would be reviewed by the POTW Attorney, Public Services Managers, and Pretreatment Coordinator. Confidential files
would be kept in a locked office and file cabinet.
35. In addition to annual inspection, does the POTW periodically meet with industries to discuss pretreatment? ® Yes ❑ No
36. Is the public notified about changes in the SUO or Local Limits? ® Yes ❑ No
37. Were all industries in SNC published in the last notice? ® Yes ❑ No ❑ N/A
Permitting (Industrial Waste Survey-IWS)
38. How does the POTW become aware of new or changed Users? The Public Services Department including
Pretreatment Coordinator meet monthly to discuss any new users. All satellite communities contact the
Pretreatment Coordinator of any new potential users.
39. Once the POTW becomes aware of new or changed Users, how does the POTW determine which industries have the
reasonable potential to adversely impact the WWTP and therefore require a new permit or a permit revision? (Who is an
SIU?) IWS Short/Long Form information reviewed for type of industrial activity, flow, loading, POCs, and
categorical parameters.
NC DWR Pretreatment Audit Form Revised: December 2016 Page 3
Rating
Explanation, if Unsatisfactory
Personnel Available for Maintaining
POTW's Pretreatment Program
®S ❑M ❑U
Access to POTW Vehicles for
Sampling, Inspections, and
®S ❑M ❑U
Emergencies
Access to Operable Sampling
Equipment
®S ❑M ❑U
Availability of Funds if Needed for
Additional Sampling and/or Analysis
®S ❑M ❑U
Reference Materials
®S ❑M ❑U
Staff Training (i.e. Annual and
Regional Workshops, Etc.)
®S ❑M ❑U
Computer Equipment (Hardware and
Software)
®S ❑M ❑U
30. Does the POTW have an adequate data management system to run the pretreatment program? ® Yes ❑ No
Explain Yes or No. Excell
31. How does the POTW recover the cost of the Pretreatment Program from their industries? Explain.
Surcharges, penalties, SIU performs resampling for violations found during POTW sampling event.
Public Perception/ Participation
32. Are there any local issues affecting the pretreatment program (e.g.. odor, plant closing, new or proposed plants)?
❑ Yes ® No If yes, Explain.
33. Has any one from the public ever requested to review pretreatment program files? ❑ Yes ® No
If yes, Explain procedure. If no, how would the request be addressed? Written request would have to be submitted and
reviewed/approved by POTW's Attorney. Files would be reviewed at the Pretreatment Office under the supervision of
the Pretreatment Coordinator.
34. Has any industry ever requested that certain information remain confidential from the public? ® Yes ❑ No If yes, Explain
procedure for determining whether information qualified for confidential status, as well as procedure for keeping files confidential
from public. If no how would the request be addressed? Written request would have to be submitted and the documentation
would be reviewed by the POTW Attorney, Public Services Managers, and Pretreatment Coordinator. Confidential files
would be kept in a locked office and file cabinet.
35. In addition to annual inspection, does the POTW periodically meet with industries to discuss pretreatment? ® Yes ❑ No
36. Is the public notified about changes in the SUO or Local Limits? ® Yes ❑ No
37. Were all industries in SNC published in the last notice? ® Yes ❑ No ❑ N/A
Permitting (Industrial Waste Survey-IWS)
38. How does the POTW become aware of new or changed Users? The Public Services Department including
Pretreatment Coordinator meet monthly to discuss any new users. All satellite communities contact the
Pretreatment Coordinator of any new potential users.
39. Once the POTW becomes aware of new or changed Users, how does the POTW determine which industries have the
reasonable potential to adversely impact the WWTP and therefore require a new permit or a permit revision? (Who is an
SIU?) IWS Short/Long Form information reviewed for type of industrial activity, flow, loading, POCs, and
categorical parameters.
NC DWR Pretreatment Audit Form Revised: December 2016 Page 3

40. Does the POTW receive waste from any groundwater remediation projects (petroleum, CERCLA) or landfill leachate?
®Yes ❑No If Yes, How many are there? 2
Please list each site and how it is permitted, if applicable. Quality Oil (groundwater remediation)/local permit and
Caldwell County Landfill Leachate
41. Does the POTW accept waste by (mark if applicable) ® Truck ❑Dedicated Pipe ❑ NA
42. If the POTW accepts trucked waste, what controls are placed on this waste? (example. designated point, samples drawn,
manifests required) Henry Fork WWTP — Caldwell County Leachate hauled via tanker to designated point with
samples drawn and manifests maintained. Septage haulers have a designated point in the Henry Fork WWTP's
collection system (Brookford) with each hauler being tracked by an electronic monitoring system.
43. How does the POTW allocate its loading to industries? Mark all that apply
❑ Uniform Limits ® Historical Industry Need ❑ By Surcharge ® Categorical Limits ❑ Other
Explain Other:
44. Review POTW's copies of current allocation tables for each WWTP. Are there any over allocations? ❑ Yes ® No
If yes, what parameters are over allocated?
45. If yes to #44, What is being done to address the over allocations? (short-term IUPs, HWA to be revised, pollutant study, etc.)
46. Does the POTW keep pollutant loading in reserve for future growth / safety? ® Yes ❑ No
If yes, what percentage of each parameter 10%
47. Has the POTW experienced any difficulty in allocation? (for example: adjudication by an industry) ❑ Yes ® No
If yes, Explain.
48. How does the POTW decide on which pollutants to limit in the permits? Monitor for? (for example: were only those pollutants
listed on the application limited; categorical parameters; NPDES Pollutants of Concern) NPDES POCs, categorical parameters.
49. How does the POTW decide what the monitoring frequency should be for the various pollutants in industry permits? Explain.
New SIU would be required to monitor monthly for one year to determine baseline. All SIUs are required to monitor three
times per six-month period at a minimum.
Permit Compliance
50. Does the POTW currently have or during the past year had any permits under adjudication? ❑ Yes ® No
If yes, which industries? What was (will be) the outcome of the adjudication?
51. Demonstrate how the POTW judges compliance. This should include compliance judgment on all violations of limits, reporting
requirements, and permit conditions, as well as for SNC. Compliance Judgment Worksheet used for SNC determinations,
violations (limit, monitoring, reporting, permit conditions, etc.) are addressed per ERP.
52. Does the POTW use the Division's model inspection form or equivalent? ® Yes ❑ No
If no, does the POTW form include all Division data? ❑ Yes ❑ No
53. Were all SlUs evaluated for the need of a slug/spill control plan during their most recent inspections? ® Yes ❑ No
If no, Explain.
54. What criteria are used to determine if a slug/spill control plan is needed? POTW requires all SIUs to have a slug/spill control
plan.
55. What criteria does the POTW use to determine if a submitted slug/spill control plan is adequate? All emergency contacts kept
updated, proper secondary containment/chemical storage practices, presence of emergency response equipment.
56. How does the POTW decide where the sample point for an SIU should be located? Sampling is preferred only at the regulated
waste stream.
57. Has the POTW established a procedure to ensure that representative samples will be taken by the POTW or SIU each time?
(example: correct location; proper programming of sampler; clean equipment; swirling the sample bucket uniformly)
POTW: ® Yes ❑ No SIU: ® Yes ❑ No If yes, Explain. Sampling SOPS and sampler O&M manuals
NC DWR Pretreatment Audit Form Revised: December 2016 Page 4

58. Who performs sample analysis for the POTW for Metals: Pace Analytical Services
Conventional Parameters: POTW's on-site certified lab
Organics: Pace Analytical Services
59. Explain the Chain of Custody Procedure used for both in house and commercial lab samples.
POTW uses internal COC and/or contracted lab's COC; SIU's used contracted lab's COC.
Long/Short Term Monitoring Plan (L/STMP) and Headworks Analysis (HWA)
60a.
60b.
60c.
60d.
60e.
60f.
Is LTMP/STMP Monitoring Being Conducted at Appropriate Locations and Frequencies? ® YES ❑ NO
Are Correct Detection Levels being used for all LTMP/STMP Monitoring? ® YES ❑ NO
Is LTMP/STMP Data Maintained in Table or Equivalent? ® YES ❑ NO Is Table Adequate? ® YES ❑ NO
All LTMP/STMP effluent data on Discharge Monitoring Report (DMR)? ® YES ❑ NO
If NO to any above, list violations
Should any Pollutants of Concern be Eliminated from or Added to LTMP/STMP? ❑ YES ® NO
If yes, which ones? Eliminated: Added:
61. Do you complete your own headworks analysis (HWA) ? ❑ Yes ® No
If no, who completes your HWA? McGill & Associates Phone (5.L8)328--2024
62. Do you have plans to revise your HWA in the near future? ® Yes ❑ No
If yes, what is the reason for the revision? (mark all that apply) ❑Increased average flow ❑NPDES limits change
❑More LTMP data available ❑Resolve over allocation 05 year expiration ®Other
Explain. Henry Fork WWTP's HWA will be updated once sampling for Bis (2-ethylhexyl) phthalate and oil & grease
(according to the LTMP) is performed.
63. In general, what is the most limiting criteria of your HWA? ❑Inhibition ❑ Pass Through ®Sludge Quality
64. Do you see any way to increase your loading in the future (Example: obtaining more land for sludge disposal)? ❑ Yes ❑ No
Explain. N/A — both WWTPs have sufficient capacity.
NC DWR Pretreatment Audit Form Revised: December 2016 Page 5

Summary
65. Do you plan any significant changes to the pretreatment program or changes to the WWTP that may affect pretreatment? No
INDUSTRIAL USER PERMIT (IUP) FILE REVIEW
66. User Name
1. Ward Hosiery
2. Catawba Valley Medical Center IF
3. Hickory Dyeing
& Winding
67. IUP Number
0027
003
0008
68. Does File Contain Current Permit?
® Yes ❑ No
® Yes ❑
F ® Yes ❑ No
69. Permit Expiration Date
7/7/21
7/7/21
7/7/19
70. Categorical Standard Applied (I.E. 40 CFR, Etc.) Or N/A
N/A
460
410
71. Does File Contain Permit Application Completed Within One Year Prior
® Yes ❑ No
®Yes ❑ No
® Yes ❑ No
to Permit Issue Date?
72. Does File Contain Inspection Completed Within Last Calendar Year?
® Yes ❑ No
® Yes ❑ No
® Yes ❑ No
73. a. Does File Contain Slug/Spill Control Plan?
a. ®Yes []No
a. ®Yes ❑No
a. ®Yes []No
b. If No, is One Needed? See Inspection Form from POTW
b. [-]Yes [-]No
b. []Yes ❑No
b. ❑Yes ❑No
74. For 40 CFR 413 and 433 TTO Certification, Does File Contain a Toxic
❑Yes❑No®N/A
❑Yes❑No®N/A
❑Yes❑NoON/A
Organic Management Plan (TOMP)?
75. a. Does File Contain Original Permit Review Letter from Division?
a. ®Yes ❑No
a. ®Yes ❑No
a. ®Yes []No
b. All Issues Resolved?
b.❑Yes❑No®N/A
b.❑Yes❑No®N/A
b.❑Yes❑No®N/A
76. During Most Recent Semi -Annual Period, Did POTW Complete its
® Yes ❑ No
® Yes ❑ No
1[
® Yes ❑ No
Sampling as Required b IUP, including Flow?
77. Does File Contain POTW Sampling Chain -Of -Custody Forms?
® Yes ❑ No
® Yes ❑ No
® Yes ❑ No
78. During Most Recent Semi -Annual Period, Did SIU Complete its
®Yes❑No❑N/A
F
®Yes❑No❑N/A
®Yes❑No❑N/A
1
Sampling as Required b IUP, includingFlow?
79. During Most Recent Semi -Annual Period, Did SIU submit all reports on❑Yes®No❑N/A
®Yes❑No❑N/A
®Yes❑No❑N/A
time?
80a. For categorical IUs with Combined Wastestream Formula (CWF), does
❑Yes❑No[D
❑Yes❑No®N/A
❑Yes❑NoON/A
file includeprocess/dilution flows as Required by IUP?
80b. For categorical IUs with Production based limits, does file include
❑Yes❑NoON/A
❑Yes❑NoNN/A
❑Yes❑NoON/A
production rates and/or flows as Required by IUP?
81. During Most Recent Semi -Annual Period, Did POTW Identify All❑Yes❑NOON/A
®Yes❑No❑N/A
❑Yes❑NOON/A
Limits Non -Compliance from Both POTW and SIU Sampling?
82. During Most Recent Semi -Annual Period, Did POTW Identify All
®Yes❑No❑N/A
❑Yes❑NoNN/A
❑Yes❑No®N/A
Reporting_Non-Compliance from SIU Sampling?
83. a. Was POTW Notified by SIU (Within 24 Hours) of All Self-
a.❑Yes❑No®N/A
a.❑Yes❑No®N/A
a.❑Yes❑No®N/A
Monitoring Violations?
b. Did Industry Resample and submit results to POTW within 30 Days?
b•❑Yes❑No®N/A
b.®Yes❑No❑N/A
b.❑Yes❑No®N/A
c. If applicable, did POTW resample and obtain results within 30 days of
becoming aware of SIU limit violations in the POTW's sampling of SIU?
c.❑Yes❑No®N/A
a❑Yes❑No®N/A
c.❑Yes❑No®N/A
84. During Most Recent Semi -Annual Period, Was SIU in SNC?
❑ Yes ® No
❑ Yes ® No
I ❑ Yes ® No
85. During Most Recent Semi -Annual Period, Was Enforcement Taken as
®Yes❑No❑N/A
®Yes❑No❑N/A
❑Yes❑No®N/A
Specified in POTW's ERP (NOVs, Penalties, timing, etc.)?
1 11
86. Does File Contain Penalty Assessment Notices?
0Yes0No[9
❑Yes❑No[D
❑Yes❑No®N/A
87. Does File Contain Proof Of Penalty Collection?
❑Yes❑No[D
❑Yes❑No®N/A
❑Yes❑No®N/A
88. a. Does File Contain Any Current Enforcement Orders?
a.❑Yes❑No®N/A
a.❑Yes❑No®N/A
a.❑Yes❑No®N/A
b. Is SIU in Compliance with Order?
b.❑Yes❑No®N/A
b.❑Yes❑No®N/A
b.❑Yes❑No®N/A
89. Did POTW Representative Have Difficulty in Obtaining Any Requested
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
Information For You?
FILE REVIEW COMMENTS:
14. Kleen Tech was in SNC for the second half of 2017 for oil & grease TRC limit violations.
72. POTW performed SIU inspections on 9/27/17 (Ward Hosiery), 8/15/17 (Catawba Valley Medical Center), and 10/26/17
(Hickory Dyeing & Finishing).
78. The following labs were contracted by the SIUs for sampling/analyses: Pace Analytical Services (Ward Hosiery), Statesville
Analytical (Catawba Valley Medical Center), and Water Tech Labs (Hickory Dyeing & Finishing).
NC DWR Pretreatment Audit Form Revised: December 2016 Page 6

81/85. Catawba Valley Medical Center was issued a Notice of NonCompliance (NoNC) on 2/12/18 for TSS and zinc limit violations
during the January 2018 POTW sampling event.
82/85. Ward Hosiery was issued a Notice of NonCompliance (NoNC) on 3/7/18 for the late reporting of the January 2018 self-
monitoring data.
INDUSTRY INSPECTION ICIS CODING:
Main Program Permit Number MM/DD/YY
INIC10 10 12 10 14 10 11 I 107112 1181
1. Industry Inspected: Ward Hosiery Company, Inc.
2. Industry Address: 1410 13' Street SW, Hickory, NC 28603
3. Type of Industry/Product: Textile (Dyeing & Finishing)/Socks
4. Industry Contact: Richard Ward Title: Owner Phone: [phone] Fax: [phone]
5. Does the POTW Use the Division Model Inspection Form or Equivalent? ® Yes ❑ No
6. Did the POTW Contact Conduct the Following Parts of the Industrial Inspection Thoroughly?
Comments:
A. Initial Interview
® Yes
❑ No
B. Plant Tour
® Yes
❑ No
C. Pretreatment Tour
® Yes
❑ No
D. Sampling Review
® Yes
❑ No
E. Exit Interview
® Yes
❑ No
Industrial Inspection Comments:
The facility operates eight hours per day and five days per week with eighteen (18) employees. All wastewater flows into a trough
prior to flowing into the POTW's sewer system. There are no pretreatment processes/units.
AUDIT COMMENTS:
The POTW's records were organized and well maintained. This Office recommends that the Pretreatment Coordinator be given
copies of the IJAs (currently being kept at the Public Services Department Office). The POTW's Industrial Pretreatment
Program was being properly implemented.
NOD: ❑ Yes
NOV: ❑ Yes
QNCR: ❑ Yes
POTW Rating:
Satisfactory ® Marginal ❑ Unsatisfactory ❑
DcuSignedd by:
�E—',,96D90CC3437
23
Audit COMPLETED BY: .. DATE: 7/18/2018
Wes Bell, WQROS, Mooresville Regional Office
NC DWR Pretreatment Audit Form Revised: December 2016 Page 7