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HomeMy WebLinkAboutNC0087858_Renewal Application_20181003 STA7i a ttr (k-,*-1 iri.2.,, -;,_.k,- .I_Y 'Tan."` r, C' ROY COOPER NORTH CAROLINA GovernorEnvironmental Quality MICHAEL S_REG-AN secretory LINDA CULPEPPER Interim Director October 03, 2018 Jim Diggs,VP Equipment And Supply Inc 4507 Hwy 74 W Monroe, NC 28110 Subject: Permit Renewal Application No. NC0087858 Equipment And Supply Inc Union County Dear Applicant: The Water Quality Permitting Section acknowledges the October 1, 2018 receipt of your permit renewal application and supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW permitting branch. Per G.S. 1506-3 your current permit does not expire until permit decision on the application is made. Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a timely manner to requests for additional information necessary to allow a complete review of the application and renewal of the permit. Information regarding the status of your renewal application can be found online using the Department of Environmental Quality's Environmental Application Tracker at: https://deq.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker If you have any additional questions about the permit, please contact the primary reviewer of the application using the links available within the Application Tracker. Sincerely, irn1243 .3+41 Wren Thedford Administrative Assistant Water Quality Permitting Section ec: WQPS Laserfiche File w/application D _EQ North Carolina Department of Environmental Quality I Division of Water Resources 1617 Mail Service Center I Raleigh,North Carolina 27699-1617 919-807-6300 c , 6 NPDES PERMIT APPLICATION - SHORT FORM C - GW For discharges associated with groundwater treatment facilities. Mail the complete application to: N. C. Department of Environment and Natural Resources Division of Water Quality / NPDES Unit 1617 Mail Service Center, Raleigh, NC 27699-1617 NPDES Permit Number NC0087858 If you are completing this form in computer use the TAB key or the up - down arrows to move from one field to the next. To check the boxes, click your mouse on top of the box. Otherwise,please print or type. 1. Contact Information: Owner Name Equipment & Supply, Inc. Facility Name Equipment & Supply, Inc. Mailing Address 4507 Highway 74 West City Monroe RECEIVED/DENR/CWR State / Zip Code NC/28110 OCT 0 1 2018 Telephone Number (704)289-6565 - Wotcr Resourues Fax Number (704)283-1206 Permitting Section e-mail Address tim@equipsy.com 2. Location of facility producing discharge: Check here if same as above Egi Street Address or State Road City State / Zip Code County 3. Operator Information: Name of the firm, consultant or other entity that operates the facility. (Note that this is not referring to the Operator in Responsible Charge or ORC) Name Harmon Environmental, PA Mailing Address 615 Bruce Thomas Road City Monroe State / Zip Code NC/28112 Telephone Number (704)764-5694 Fax Number (704)764-5694 4. Ownership Status: Federal ❑ State ❑ Private ® Public ❑ Page 1 of 3 C-GW 03/05 NPDES PERMIT APPLICATION - SHORT FORM C - GW For discharges associated with groundwater treatment facilities. 5. Products recovered: Gasoline ❑ Diesel fuel ❑ Solvents ® Other 6. Number of separate discharge points: 1 RECEIVED/DFNR/DWR Outfall Identification number(s) 001 OCT 01 2018 7. Frequency of discharge: Continuous ® Intermittent ❑ Water Resources Permitting Section If intermittent: Days per week discharge occurs: Duration: 8. Treatment System Design flow 0.00072 MGD 9. Name of receiving stream(s) (Provide a map showing the exact location of each outfall, including latitude and longitude): Stuarts Creek 10. Please list all additives to the treatment system, including chemicals or nutrients, that have the potential to be discharged. None 11. Is this facility located on Indian country? (check one) Yes ❑ No El 12. Additional Information All applicants (including renewals): • A USGS topographical map (or copy of the relevant portion) which shows all outfalls • A summary of the most recent analytical results (effluent data, if available) containing the maximum values for each chemical detected NEW Applicants only: • Engineering Alternative Analysis • Description of remediation treatment system components, capacities, and removal efficiency for detected compounds. • If the treatment system will discharge to a storm sewer, written approval from the municipality responsible for the sewer. • A list of any chemicals found in detectable amounts at the site, with the maximum observed concentration reported for each chemical (the most recent sample must be collected less than one year prior to the date of this application) • For petroleum-contaminated sites -Analyses for Volatile Organic Compounds (VOC) should be performed. Analyses for any fuel additives likely to be present at the site and for phenol and lead should also be performed. • For sites contaminated with solvents or other contaminants - EPA Method 624/625 analysis should be performed. Page 2 of 3 C-GW 03/05 NPDES PERMIT APPLICATION - SHORT FORM C - GW For discharges associated with groundwater treatment facilities. 13. Applicant Certification I certify that I am familiar with the information contained in the application and that to the best of my knowledge and belief such information is true, complete, and accurate. Jim Diggs Vice President Printed name of Person Signing Title f4r, 9/0,-/.,/0 Signature of ...p ant / Date North Carolina General Statute 143-215.6 (b)(2) provides that: Any person who knowingly makes any false statement representation, or certification in any application, record, report, plan, or other document files or required to be maintained under Article 21 or regulations of the Environmental Management Commission implementing that Article, or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under Article 21 or regulations of the Environmental Management Commission implementing that Article, shall be guilty of a misdemeanor punishable by a fine not to exceed $25,000, or by imprisonment not to exceed six months, or by both. (18 U.S.C. Section 1001 provides a punishment by a fine of not more than $25,000 or imprisonment not more than 5 years, or both, for a similar offense.) 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WWTF Facility a •ya res 2..�1Y'#FT r t F� ys*f' Latitude: 32°02'34"N Longitude: 80°36'42"w Location "" >i�=`ri rti>x t: f Stream Class: WS-Ill Receiving Stream: UT to Stewarts Creek not to scale -.,,,;,.,:r:?'y...-.. Segment Number: 13-17-36-9(1) State Grids: G16SE ,,::r Drainage Basin: Yadkin Pee Dee Permitted Flow: 0.0216 MGD Sub-Basin: 03-07-14 XR1C: 03040105 USGS Ouads: Bakers,NC North NPDES Permit NC0087858 Union County Pace Analytical Services,LLC . aceAnalytical 9800 KmceyAve. Suite 100 www.pacelabs.com Hunterswlle,NC 28078 (704)875-9092 August 09, 2018 Mr. Rick Harmon Harmon Environmental 615 Bruce Thomas Road Monroe, NC 28112 RE: Project: 81 EFF 309-8/1 Pace Project No.: 92394058 Dear Mr. Harmon: Enclosed are the analytical results for sample(s) received by the laboratory on August 01, 2018. The results relate only to the samples included in this report. Results reported herein conform to the most current, applicable TNI/NELAC standards and the laboratory's Quality Assurance Manual, where applicable, unless otherwise noted in the body of the report. If you have any questions concerning this report, please feel free to contact me. Sincerely, Kevin Herring kevin.herring@pacelabs.com 1(704)875-9092 HORIZON Database Administrator Enclosures 0,QN s ‘g" "TS REPORT OF LABORATORY ANALYSIS This report shall not be reproduced,except in full, ;9 �y without the written consent of Pace Analytical Services,LLC Page 1 of 12 RA aceAnalytical® Pace Analytical Services,LLC 9800 Kincey Ave. Suite 100 www.pacelabs.com Huntersville,NC 28078 (704)875-9092 CERTIFICATIONS Project: 81 EFF 309-8/1 Pace Project No.: 92394058 Charlotte Certification IDs 9800 Kincey Ave.Ste 100,Huntersville,NC 28078 South Carolina Certification#:99006001 Louisiana/NELAP Certification#LA170028 Florida/NELAP Certification#:E87627 North Carolina Dnnking Water Certification#:37706 Kentucky UST Certification#:84 North Carolina Field Services Certification#:5342 VirginiaNELAP Certification#:460221 North Carolina Wastewater Certification#.12 ( REPORT OF LABORATORY ANALYSIS This report shall not be reproduced,except in full, without the written consent of Pace Analytical Services,LLC. Page 2 of 12 Pace Analytical Services,LLC • aceAnalytical® 9800Kincey Ave te 100 Huntersv Ile,NC'28078 wwwpacelabs.com (704)875-9092 SAMPLE ANALYTE COUNT Project: 81 EFF 309-8/1 Pace Project No.: 92394058 . Analytes Lab ID Sample ID Method Analysts Reported Laboratory 92394058001 81 EFF 309 EPA 624 1 GAW 11 PASI-C . REPORT OF LABORATORY ANALYSIS This report shall not be reproduced,except in full, without the written consent of Pace Analytical Services,LLC. Page 3 of 12 J Pace Analytical Services,LLC a'ceAnalytical® 9800 Kiiy Suite 100 n ele, www.pacelabs.com (704)875-9092 PROJECT NARRATIVE Project: 81 EFF 309-8/1 Pace Project No.: 92394058 Method: EPA 624.1 Description: 624 Volatile Organics , Client: Harmon Environmental Date: August 09,2018 General Information: 1 sample was analyzed for EPA 624.1. All samples were received in acceptable condition with any exceptions noted below or on the chain-of custody and/or the sample condition upon receipt form(SCUR)attached at the end of this report. Hold Time: The samples were analyzed within the method required hold times with any exceptions noted below. Initial Calibrations(including MS Tune as applicable): All criteria were within method requirements with any exceptions noted below. Continuing Calibration: All criteria were within method requirements with any exceptions noted below. Internal Standards: All internal standards were within QC limits with any exceptions noted below. Surrogates: All surrogates were within QC limits with any exceptions noted below. Method Blank: All analytes were below the report limit in the method blank,where applicable,with any exceptions noted below. Laboratory Control Spike: All laboratory control spike compounds were within QC limits with any exceptions noted below. Matrix Spikes: All percent recoveries and relative percent differences(RPDs)were within acceptance criteria with any exceptions noted below. Additional Comments: This data package has been reviewed for quality and completeness and is approved for release. REPORT OF LABORATORY ANALYSIS This report shall not be reproduced,except in full, without the written consent of Pace Analytical Services,LLC Page 4 of 12 aceAnalytical® Pace Analytical Services,LLC 9800 KinceyAve. Suite 100 wwwpacelabs coalHuntersvdle,NC 28078 1 (704)875-9092 ANALYTICAL RESULTS Project: 81 EFF 309-8/1 Pace Project No.: 92394058 Sample: 81 EFF 309 Lab ID: 92394058001 Collected' 08/01/18 08:20 Received: 08/01/18 12:52 Matrix:Water Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual 624 Volatile Organics Analytical Method:EPA 624.1 1,1-Dichloroethane ND ug/L 2.0 1 08/08/18 21:03 75-34-3 1,1-Dichioroethene ND ug/L 2.0 1 08/08/18 21:03 75-35-4 cis-1,2-Dichloroethene ND ug/L 2.0 1 08/08/18 21:03 156-59-2 trans-1,2-Dichloroethene , ND ug/L 2.0 1 08/08/18 21:03 156-60-5 Tetrachioroethene ND ug/L 2.0 1 08/08/18 21:03 127-18-4 1,1,2-Trichloroethane ND ug/L 2.0 1 08/08/18 21:03 79-00-5 Trichloroethene ND ug/L 2.0 1 08/08/18 21:03 79-01-6 Vinyl chloride ND ug/L 2.0 1 08/08/18 21:03 75-01-4 Surrogates 4-Bromofluorobenzene(S) 104 % 70-130 1 08/08/18 21:03 460-00-4 Toluene-d8(S) 118 % 70-130 1 08/08/18 21:03 2037-26-5 1,2-Dichloroethane-d4(S) 97 % 70-130 1 08/08/18 21:03 17060-07-0 REPORT OF LABORATORY ANALYSIS This report shall not be reproduced,except in full, Date:08/09/2018 03:47 PM without the written consent of Pace Analytical Services,LLC Page 5 of 12 ® Pace Analytical Services,LLC aceAnalytical® 9800 KinceyAve. Suite 100 wwwpace/abs.com Huntersville,NC 28078 (704)875-9092 QUALITY CONTROL DATA Project: 81 EFF 309-8/1 Pace Project No.: 92394058 QC Batch: 423817 Analysis Method: EPA 624.1 QC Batch Method: EPA 624.1 Analysis Description: 624 MSV Associated Lab Samples: 92394058001 METHOD BLANK: 2344861 Matrix: Water Associated Lab Samples: 92394058001 Blank Reporting Parameter Units Result Limit Analyzed Qualifiers 1,1,2-Trichloroethane ug/L ND 2.0 08/08/18 19:56 1,1-Dichloroethane ug/L ND 2.0 08/08/18 19:56 1,1-Dichloroethene ug/L ND 2.0 08/08/18 19:56 cis-1,2-Dichloroethene ug/L ND 2.0 08/08/18 19:56 Tetrachloroethene ug/L ND 2.0 08/08/1819.56 trans-1,2-Dichloroethene ug/L ND 2.0 08/08/1819'56 Trichloroethene ug/L ND 2.0 08/08/18 19:56 Vinyl chloride ug/L ND 2.0 08/08/18 19:56 1,2-Dichloroethane-d4(S) % - 94 70-130 08/08/18 19:56 4-Bromofluorobenzene(S) % 106 70-130 08/08/18 19:56 Toluene-d8(S) % 106 70-130 08/08/18 19:56 LABORATORY CONTROL SAMPLE: 2344862 Spike LCS LCS %Rec Parameter Units Conc. Result %Rec Limits Qualifiers 1,1,2-Trichloroethane ug/L 20 19.5 98 70-130 1,1-Dichloroethane ug/L 20 20.0 100 70-130 1,1-Dichloroethene ug/L 20 21.3 107 50-150 cis-1,2-Dichloroethene ug/L 20 20.6 103 68-146 Tetrachloroethene ug/L 20 19.8 99 70-130 trans-1,2-Dichloroethene ug/L 20 214 107 70-130 Trichloroethene ug/L 20 21.2 106 65-135 Vinyl chloride ug/L 20 20.8 104 5-195 1,2-Dichloroethane-d4(S) % 100 70-130 4-Bromofluorobenzene(S) % 102 70-130 Toluene-d8(S) % 98 70-130 MATRIX SPIKE&MATRIX SPIKE DUPLICATE: 2344863 2344864 MS MSD 92394581001 Spike Spike MS MSD MS MSD %Rec Parameter Units Result Conc. Conc. Result Result %Rec %Rec Limits RPD Qual 1,1,2-Trichloroethane ug/L ND 20 20 23.6 26.1 118 130 52-150 10 1,1-Dichloroethane ug/L ND 20 20 23.1 26.3 116 131 59-155 13 1,1-Dichloroethene ug/L ND 20 20 26.6 29.8 133 149 1-234 11 cis-1,2-Dichloroethene ug/L ND 20 20 24.6 27.4 123 137 45-174 11 Tetrachloroethene ug/L ND 20 20 22.4 25 3 112 126 64-148 12 trans-1,2-Dichloroethene ug/L ND 20 20 24.9 28.7 125 144 54-156 14 Trichloroethene ug/L ND 20 20 24.8 28 0 124 140 70-157 12 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:08/09/2018 03:47 PM without the written consent of Pace Analytical Services,LLC. Page 6 of 12 Pace Analytical Services,LLC aceAnalytical® 9800Kincey Ave.Huntersw le,Suite 10 8 www.pacelabs.com (704)875-9092 QUALITY CONTROL DATA Project: 81 EFF 309-8/1 Pace Project No.: 92394058 MATRIX SPIKE&MATRIX SPIKE DUPLICATE: 2344863 2344864 MS MSD 92394581001 Spike Spike MS MSD MS MSD %Rec Parameter Units Result Conc. Conc. Result Result %Rec %Rec Limits RPD Qual Vinyl chloride ug/L ND 20 20 25.9 28.9 129 144 1-251 11 1,2-Dichloroethane-d4(S) % 111 112 70-130 4-Bromofluorobenzene(S) % 99 99 70-130 Toluene-d8(S) % 99 99 70-130 L 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.08/09/2018 03:47 PM without the written consent of Pace Analytical Services,LLC Page 7 of 12 Pace Analytical Services,LLC aceAnalytical( 1 ® 9800Kincey Ave.Huntersv Ile,NC Suite 078 100 wwwpacefabs corn (704)875-9092 QUALIFIERS Project: 81 EFF 309-8/1 Pace Project No• 92394058 DEFINITIONS DF-Dilution Factor,if reported,represents the factor applied to the reported data due to dilution of the sample aliquot. ND-Not Detected at or above adjusted reporting limit. TNTC-Too Numerous To Count J-Estimated concentration above the adjusted method detection limit and below the adjusted reporting limit. MDL-Adjusted Method Detection Limit. PQL-Practical Quantitation Limit. RL-Reporting Limit-The lowest concentration value that meets project requirements for quantitative data with known precision and bias for a specific analyte in a specific matrix. S-Surrogate 1,2-Diphenylhydrazine decomposes to and cannot be separated from Azobenzene using Method 8270.The result for each analyte is a combined concentration. Consistent with EPA guidelines,unrounded data are displayed and have been used to calculate%recovery and RPD values LCS(D)-Laboratory Control Sample(Duplicate) MS(D)-Matrix Spike(Duplicate) DUP-Sample Duplicate RPD-Relative Percent Difference NC-Not Calculable. SG-Silica Gel-Clean-Up U-Indicates the compound was analyzed for,but not detected. Acid preservation may not be appropriate for 2 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. Pace Analytical is TNI accredited.Contact your Pace PM for the current list of accredited analytes. TM-The NELAC Institute. LABORATORIES PASI-C Pace Analytical Services-Charlotte REPORT OF LABORATORY ANALYSIS This report shall not be reproduced,except in full, Date:08/09/2018 03:47 PM without the written consent of Pace Analytical Services,LLC Page 8 of 12 Pace Analytical Services,LLC aceAnalytical® 9800 KinceyAve. Suite 100 Huntersville,NC 28078 www.pacelabs.com (704)875-9092 QUALITY CONTROL DATA CROSS REFERENCE TABLE Project: 81 EFF 309-8/1 Pace Project No.: 92394058 Analytical Lab ID Sample ID QC Batch Method QC Batch Analytical Method Batch 92394058001 81 EFF 309 EPA 624.1 423817 C REPORT OF LABORATORY ANALYSIS This report shall not be reproduced,except in full, , Date:08/09/2018 03:47 PM without the written consent of Pace Analytical Services,LLC. Page 9 of 12 r Document Name: Document Revised:February 7,2018 aceAnalyticala Sample Condition Upon Recelpt(SCUR) Page 1 of 2 Document No.: Issuing Authority: F•CAR-CS-033-Rev.06 Pace Carolinas Quality Office Laboratory receiving samples: Asheville❑ EdenD Greenwood 0 Huntersvill�.e- Raleigh❑ Mechanicsville❑ Sample Condition Client Name: pr ject#: Wof : 92394058 Upon Receipt � rAdU7SPS r nt Courier: Fe Ex UPS Client IJiIII:II:I:1:JJ1I:IIIITIIL 9239405❑Commercial ce ❑Other: 8 . _ _ _ -- . _ Custody Seal Present? ❑Yes C:IAld' Seals Intact? Oyes ❑ryp� Date/Initials Person Examining Contentsi Packing Material: ❑Bubble Wrap Bubble Bags ❑None 0 Other Biological Tissue Frozen? Thermometer� Type of ice: �-, et/❑elue ❑Yes ❑No B}Itf�A gjw un ID; 2T040 ts►w ['None Cooler Temp(°C): 7• % Correction Factor:Add/Subtract(•C) +0.4 Temp should be above freezing to 6'C Cooler Temp Corrected(°C): ❑Samples out of temp criteria.Samples on Ice,cooling process has begun USDA Regulated Soll ( N/A,water sample) Did samples ori i e in a quarantine zone within the United States:CA,NY,or Sc(check maps)? Did samples originate from a foreign source(Internal Ily, Oyes No including Hawaii and Puerto Rico)?❑yesNo Comments/Discrepancy: Chain of Custody Present? ONo ON/A 1. Samples Arrived within Hold Time? es ONo ON/A 2. Short Hold Time Analysis(<72 hr.)? Oyes ,ofo ON/A 3. Rush Turn Around Time Requested? Oyes ,BIf' ON/A 4. Sufficient Volume? es ONo ON/A 5. Correct Containers Used? res ❑No ON/A 6. -Pace Containers Used, Zfrel ONo ON/A Containers intact? Yes ONo ❑N/A 7. Dissolved analysis:Samples Field Filtered? Oyes -ONo —BOA 8. Sample Labels Match COC? fare-Se- ❑No ON/A 9. -Includes Date/Time/ID/Analysis Matrix: � Headspace in VOA Vials(>5-6mm)7 DyesNo N/A 10. Trip Blank Present? :Nes No ON/A 11. Trip Blank Custody Seals Present? Oyes ONo 20-A' COMMENTS/SAMPLE DISCREPANCY Field Data Required? Dyes ONo Lot ID of split containers: CUENT NOTIFICATION/RESOLUTION Person contacted: Date/Time: Project Manager SCURF Review: Date: Project Manager SRF Review: Date: Page 10 of 12 Co N Y O b CO - a in A W N w fD g hemp 4 m rn < iF � � 0 / // / //� /// / / * m3 n Ix m BP4U-125 mL Plastic Unpreserved(N/A)(CI-) m v o O 2 o a St -i BP3U-250 mL Plastic Unpreserved(N/A) 3 < m 3 A msa BP2U-500 ml.Plastic Unpreserved(N/A) d D O' 2 �n 9 7 o BP1U-1 liter Plastic Unpreserved(N/A) c _S 13 ter, z fir 0 13 0 co o ; 2 ;7;/.////Zr" / �/ BP4S-125 ml Plastic H2504(pH<2)(Ci_) f % ya �,F.2 c / BP3N-250 ml plastic HNO3(pH<2) p3 °imn' 8P42-125 mL Plastic 2N Acetate &NaOH(>9) { • cala x O R. Z 0 C mna 0 / BP4C-125 mL Plastic NaOH (pH>12)(Cl-) j 3 m m' n (0 rs A m at oc 2 WGPU-Wide-mouthed Glass jar Unpreserved ' 0 3ix 0 p W O 03 °�' -�; 1 AG1U-1 liter Amber Unpreserved(N/A)(CI-) !O ea -r Q ///7/ .* 1 y es fD m 3 AGIH-1 liter Amber HO(pH<2) !iD f 13 7';3i ET 'o n w n AG3U-250 ml Amber Unpreserved(N/A)(Cl-) o A oai p 3 w O / /� O d A O w n D AGI5-1 liter Amber H2504(pH<2) 0 3 r= 3 Ncm b 0 W N W ' 'O .'i n c AG3S-250 ml.Amber H2504(pH<2) it. ,. 0 z / .. m of c // 7 AG3A(DG3A)-250 mL Amber NH4CI(N/A)(CI-) o '• m m a N m ii �\-1DG9H-40 mL VOA HCI (N/A) m N 3 m D a. 0 n E `v N VG9T110 mL VOA Na25203(N/A) n A er nN 1p 3 VG9U-40 mL VOA Unp(N/A) m .m.. ID - o in DG9P-40 mL VOA H3PO4(N/A) m' r o o VOAK(6 utak per kit)-5035 kit(N/A) .. d c p 1 Z m Q m ID c V/GK(3 vials per kit)-VPH/Gas kit(N/A) ( .. _ N p o .o. .. o c .o m c o SPST 125 ml Sterile Plastic(N/A-lab) ! N o'u �' m mn 'n 1 �n c 03 r .. SP2T-250 ml Sterile Plastic(N/A-lab) N A♦ e s o� = 1° / .//V A xi < / / o 0 N E n / 3 A o -2 El / _ tY v g ,4/71,:/ / / BP3A 250 nil.Plastic(NN2)2504(9 3-9.7) 7 C m do -o' [Y O AGOU-100 ml Amber Unpreserved vials IN/A) ce- oa ro s - repo co a VSGU-20 ml Scintillation vials (N/A) ro `D DG9U-40 mL Amber Unpreserved vials(N/A) m Co FL N 02 sem' CHAIN-OF-CUSTODY/Analytical Request Document FaeeAnalytieal n The Chain-of-Custody is a LEGAL DOCUMENT.All relevant fields must be completed accurately. www.pacelabs.com . Section A Section B Section C Page: of V Required Client Information. Required Project Information- Invoice Information 1 Compo y: q Report To. Allenhon r 5aj,� V�,.y, ri, !-?CA,rivN ,t^ :5,71)to. l 1/3 �1 j�,t�2,�t x� , 2 2 3 6 9 9 2 _ Address' -Copy Copy To: C any Name. r.t S 17/!Jt-37'( vr,c, .1 ¢rr a.1.1,�,— w,r/ L GULATORY AGENCY A NPDES 1- f'GROUND WATER DRINKING WATER Erppaill To. Purchase Order No.' Pace Quote AA IfrDt'+,:v1:�1y ( V{Gjn.�r-i-.�� Reference. r UST I- RCRA I- OTHER lR:n 1.dart 1.1,.0„,1 Fax Project Name. Paco Prolect Manager. Site Location Requested Duo Date/TAT: Project Number. Paco Profile P. STATE: Kk i- Requested Analysis Filtered(Y/N) Suction D Matrix Codes v —.RequlrodChcnt Information MATRIX I CODF o COLLECTED Preservatives• y Dnnk, ng Water DW A VO z Water WT E n O Waste Water WW COMPOSITE COMPOSITE t- PtOduct P n m START END/GRAB - Sari/Sohd SL 8 00 Z SAMPLE ID WOiipe WP a c? `F0 cc w m C C L /0,. Sample IDs MUST BE UNIQUE Tissue TS AR O a 0. H m el Fn `o Other OT 0 1- to N 0 P.:1 Z Z to U # x J it J 17 y O C T C-0 Z Q 0- u_ m 0„, O rn L us C = a F < N Q 0 CZ U f0 a: G1 E. < (� y DATE TIME DATE TIME N 7 I I Z Z 0 .► Gr �, FL Pace Project No./Lab I.D. of 13o ( „ir ei �..Ii/,E. c z.. ? I`1t7 \ 2 3 4 _ 5 6 7 8 9 1 10 11 1 — 12 ADDITIONAL COMMENTS R UNQUISHED BY/AFFILIATION DATE TIME ACCEPTED BY/AEFJLIATION DATE TIME 1 SAMPLE CONDITIONS _ cv, Vi/f, ,- -4 �^ Y4 , ie.)--?--! �� 7 'I, , — I —13 IM co SAMPLER NAME AND SIGNATURE a ORIGINAL t IV PRINT Name of SAMPLER: t c o^ ` iC�4'G fl:- n v> oVZ Z_ o 6/ ��1 SIGNATURE of SAMP "�� 44,......-----1. �'/t I DATE Signed 644.... f F u cj `}' E IV ,�-i�>'� /'V"i/�� (MMIDDIYY): , rn giy 'Important Note•By smtung this form you are accepting Pace's NET 30 day payment terms and agreeing to tale charges of 1 5%per month for any invoices not pad within 30 days F-ALL-Q-02Orev.07,15-May-2007