NCS000134_MONITORING INFO_20190213

STORMWATER DIVISION CODING SHEET
NCS PERMITS
PERMIT NO.
��C�j `� � b 13l/
DOC TYPE
❑FINAL PERMIT
MONITORING REPORTS
❑ APPLICATION
❑ COMPLIANCE
❑ OTHER
� U � Cj
DOC DATE
❑
YYYYMMDD

Avoca, LLC
PO Box 129
ArA 841 Avoca Farm Rd
xt, Avoca, LLC Merry }fill, MC 27957
Phone:[phone]
The World's Premier Botanical Extraction Company Fax: [phone]
Date: January 31, 2019
Division of' Water Quality
Attn: Central Files FC :.
1617 Mail Service Center FES 13 2U �,
Raleigh, NC 27699-1617
CLk ',"AL FK-ES
Subject: Avoca. I,I,C - Permit No. NCS000134 - 13ertie County OWR SECTION
1) Stormwatcr Discharge Outfall Monitoring; Report
2) Stormwater Discharge Outfall Qualitative Monitoring Reports
Report for .July - December 2019
The storm water samples were collected during the first rainfall event in .January
for the December sampling because there was no representative event that occurred
in December during a time period that the samples could be analyzed.
Enclosed you will find the original and 1 copy of the compliance reports on lorms SWU-
246 and SWU-242 as required by Permit No. NCS000134. 'These reports arc; required
semi-annually for the period from January -June and July — December.
It should be noted that one of the benchmark values was exceeded with these
samples. The following benchmark was exceeded:
- The COD benchmark is 120 mg/L. The result from Outfall 001 was 167
m g/L.
Avoca, LL,C. has followed the •Tier 1 and •Tier 2 programs outlined in the permit to
investigate the causes for exceeding the benchmarks. It has been determined that the
benchmarks have been exceeded due to the increases amounts of sage material that are
present in the run-off to Outfall 003. Avoca began monitoring outfall 003 monthly in
January 2013 due to past samples exceeding the benchmarks for both TSS and COD.
Samples have been collected, analyzed, and the results have been submitted monthly to
NCDENR. The COD has been reduced this month.

If you have any questions, please contact me at (252) 482-2I 33 extension 287.
Sincerely,
Brian Conner
Environmental, Health, & Safety Manager.
Avoca, L,I.,C

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 000 l 3 H SAMPLES COLLECTED DURING CALENDAR YEAR:
(This monitoring report shall be received by the Division uo later thou 30 days from
the date the facility receives the sampling results from the laboratory.)
FACILITY NAME AV C<X i,, L
PERSON COLLECTING SAMPLE(S) r'Coe_v-
CERTIFIED LABORATORY(S) E n,4; ^ e+ 1 t ED
a
FEB 13 2019
Part A: Specific Monitoring Requirements CENTRAL FILES
nXArR SFCiION
COUNTY 9,-_Y'f %e-
PHONE NO. (ZSZ) %4 bZ-'Z.13_'�
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Outfall
No.
Date
Sample
50050
Total
Flow if a
Total
Rainfall
N ��ro C�
L4ad
p1�oS 1�OruS
SS
C.o ID
mo/ddl r
MG
inches
L7
1 L
rwg L
oo 1
ti o
.4.00S
.S
1
.`L
3
I %y t id • ,
. O S
O - CtC6
4
0.00 ,
-1; Z2
OLe
Ato
o0q
LA
N
0.
40.005
0.09
4Z.(o
420
-b0
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes V_a
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
'00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
molddl r
MG
inches
m /l
m /l
unit
al/mo
Form S WU-247, last revised 21212012
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date k - N-2, 0
Total Event Precipitation (inches): 0.9
Event Duration (hours): _._ (only if applicable— see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable— see permit.)
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 fines and imprisonment for knowing violations."
(Signature of Perm
}
(Date)
Form SWU-247, last revised 21212012
Page 2 of 2

, NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this form, please visit: htt ortal.ncd enr.or well lr n pde tormwater
Permit No.: N/C/�/O/Q/11//_/ or Certificate of Coverage No.:
Facility Name:
County: Zer
Phone No. Z52- 4N.- 2133
Inspector: 1dr;nv, tZw►d,�--
Date of Inspection: k-14- 20 _
Time of Inspection: O` %LiS
Total Event Precipitation (inches): 0
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
dyes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions, if applicable.
A "representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
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 DWQ Regional Office.
By this signature, I certify that this report is accurate and complete to the best of my knowledge:
AA�6=-
(Signature of Permittee or Designee)
Pagel of 2
SWU-242, Last modified 7/31/2013

1. Outfall Description:
Outfall No. Do 1 Structure (pipe, ditch, etc.)
Receiving Stream: SG WNDVI Creel4
Describe the industrial activities that occur.within the outfaal+l drainage area:
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: (Aeasc
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): _ 4)he.
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy: .
O 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:
Q 2 3 4 5
b. 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:
J 2 3 4 5
7. Is there any foam, in the stormwater discharge? Yes No
S. Is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
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 7/31/2013

4
NCDENR
Stormwater Discharge Outfall. (SDO)
Qualitative Monitoring Report
For guidance on filling out thisform, please visit: had://portal.ncdenr.org/web/lr/npdes-stormwater/
Permit No.: N/C/ 4 /U/ D/1/-3/-q/_/ or Certificate of Coverage No.:
Facility Name:
County: Ze.Y
Phone No. ZS2- LA bZ- Z13'3
Inspector: ' 7' cwx L-ovpy
Date of Inspection:
Time of Inspection: '-00
Total Event Precipitation (inches): d ' y
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
M/Yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have this requirement. PIease refer to these definitions, if applicable.
A "representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
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 DWQ 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)
Pagel of 2
SWU-242, Last modified 7/31/2013

I. Outfall Description:
Outfall No. Q0 Structure (pipe, ditch, etc.) �f e1� etch
Receiving Stream: 5&k*r-^0 n Cre-e k
Describe the industrial activitiesthatoccur-within the outfaall drainage area:
C 1 li�p'CaG.Y` h ®'S �'OiV'falr�,n j '�1`(�S 'Yir bd1. C•e � 4e.�4W v >�eG�, 5
2. Color: Describe the color of the
(light, medium, dark) as descriptors:
ge using basic colors (red, brown, blue, etc.) and tint
3. Odor: Describe any distinct odors that the discharge may have•(i.e., smells strongly of oil,
weak chlorine odor, etc.): �I'DvS- •
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
D2 3 4 5
S. 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:
Q 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:
01 2 3 4 - 5
7. Is there any foam in the stormwater discharge? Yes (No )
8. Is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
Note: Low clarity, high solids, and/or the presence of foam, oil sheen, or erosion/deposition
may he indicative of pollutant exposure. These conditions warrant further investigation.
Page 2 of 2
SWU-242, bast modified 7/31/2013

AiA
NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this form, please visit: htt :: //portal.ncdenr.orglweb/Ir/npdes-stormwate7/
Permit No.: N/C/ 4 /0/ O/1/,3/L±/_/ or Certificate of Coverage No.:
Facility Name:
County: —bev
Inspector: :!�
ne No. Z.S2— LIbZ- 2133
Date of Inspection: �kQ _.
Time of Inspection: 1 O � OS
Total Event Precipitation (inches): © • I
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
R/Yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event.' However,
some permits do not have this requirement. Please refer to these definitions, if applicable.
A "representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
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 DWQ 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)
Page 1 of 2
SWU-242, Last modified 7/3I f 2013

1. Outfall Description: n
Outfall No. b D 3 Structure (pipe, ditch, etc.) r jpQ�
Receiving Stream: S':'A1-^0'% creek
Describe the industrial activities that occur.within the outfall drainage area:
�r��mrbmcal �.s�•��c�a.�env, ®ps ���vu�r;r+as► od�ka•��VC�S. �rr�.��a�ec•es,� c�iae�aa�g Sv 1>�_cv��'S
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: Lqy'4 Q,.aH
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): Oyu,
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy: ArN
1 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:
01 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:
91
9
d2 3
Is there any foam in the stormwater discharge?
4 5
Yes [�f
Is there an oil sheen in the stormwater discharge? Yes ©o
Is there evidence of erosion or deposition at the outfall? Yes (9
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
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 7/31/2013

NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this form, please visit: http://portal.ncdennorg/well/lr/npdes-stormwater/
Permit No.: N/C/ 0/O/ O/-L///_/ or Certificate of Coverage No.: N/C/G/_/_/_/^/ti/
Facility Name:
County: zev
Inspector: �-OvMov-
Date of Inspection:.Time of Inspection: R ' 30
Total Event Precipitation (inches): 0 •1
ne No. ZS2- 4�Z` 2133
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
Vyes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." however,
some permits do not have this requirement. Please refer to these definitions, if applicable.
A "representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
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 DWQ 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)
Page 1of2
SWU-242, Last modified 7/31/2013

1. Outfall Description.:
Outfall No. - C)0q Structure (pipe, ditch, etc.)
Receiving Stream: S4-^Dn Creek
Describe the industrial activities that occur. within the outfall drainage area:
C 1 "k'Adrih O� '�Cl�fOJ+n $ i`!PS r Ce ie'T4Y v +Ph 5
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: C,\ act✓
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.):
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and S is very cloudy: .
© 2 3 4 5
S. 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:
O 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-
(D
List and describe
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 7/31/2013

NCDENR
Storrnwater Discharge OutfaIl (SDO)
Qualitative Monitoring Report
Forguidance on filling out thisform, please visit: http://portal.ncdennorg/web/1rinpdes-stormwater �
Permit No.: N/C/4/O/Q/�///_/ or Certificate of Coverage No.:
Facility Name: AVpca , .Lnc o�nara�e c�
County: Ze.Ar e- Phone No. ZS1- LA b2 2..133
Inspector: `�rsa!1.._Canv►o� _
Date of Inspection: HL-A-20
Time of Inspection: \0%20
Total Event Precipitation (inches): d •1
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
[(Yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions, if applicable.
A "representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
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 DWQ 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)
Pagel of 2
SwU-242, Last modified 7/31/2013

r
1. Outfall Description: r
Outfall No. 0b-1 Structure (pipe, ditch, etc.) �zg-
Receiving Stream: S6A"^0'% cre-ek
Describe the industrial activities that occur within the outfall drainage area:
Snion1cal Q,-An&-Lht'a%l OS �0rP0Y�n45� s�itif@S �rCr��0.+nCiS.�G�Ia��OiVcA 5�97q,92+7�'ldh'��
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: C\etxv
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.):.AJ0, - - - - ---
1
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:
01 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:
a2 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:
O 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes l'.:3"
B. Is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes G
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
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 7/31/2013

ERAmNEW % hwpmbo
AVOCA, LLC (STORMWATER SITES)
MR. BRIAN CONNER
P.O. Box 129
MERRY HILL ,NC 27957
PARAMETERS
PH (nut to he used for reporting)
COD, mg/l
Total Suspended Residue, mg/I
Total Weldahl Nitrogen as N,mgll
Total Kjeldahl Nitrogen as N,mg/I
Nitrate -Nitrite as N, mg/I
Total Phosphorus as P, mg/l
Lead, ugll
Lead, ugll
ID#: 605
DATE COLLECTED: 01/14/20
DATE REPORTED : 01/30/20
REVIEWED BY:
S%V lit
S%V #3
Sw #4
Analysis
Method
Ont.,Grab
Out.,Grab
Out.,Grub
Date Analyst
Code
7.2
7.3
6.8
01/15/20
GNB
4500HU-11
167
80
<20
01/16/20
KDS
H8000-79
59
70
<2.6
01/16/20
HJO
2540D-11
1.20
0.50
01/23/20
AKS
351.2 R2-93
2.64
01/17/20
TLH
351.2 R2-93
0.33
0.20
0.16
01/16/20
DTL
353.2 R2-93
0.54
1.22
0.09
01/23/20
TLH
365.4-74
<5.0
7
01/23/20
MTM
3113E-10
<5.0
01/29/20
INITNI
31UB-10

Environinent 1.Inc. CHAIN OF CUSTODY RECORD
P-O. Box 7085. 114 Oakinonr Dr. Paae 1 Of I
C;re-envilte NC.27$58
environment 1 inc.com
DISINFECT-ION,N
CHLORINE NI=UTiaAL1ZED AT CCLLECTtCN
Phone (2i2) 756-6208 • Fax [phone]
CHLORINE
CLIENT: 605 Week:1
U`
pH CHECK (LAB)
P
P
P
P
P
P
P
CONTAINER lYPE,PIG
,VOCA, LLC (S'TORivIWATER SITES)
NONE
SIR. BRIA_h CO\E'ER
E�
A
C
A
C
C
C
A
CHEMICAL PRESERVATIQN
O. SOX 129
1ERRY HILL NC 27937
F- A • NONE D - NAOH
o
Z52) 482-2133
�
�'
=
C B - HNO. E - HCL
_z
Q
z
Q O
Z
_�
O
.-
O
�
o 0
C - H2SC, F - ZINC ACETATE/NAOH
COLLECTION
c-) <
< rn
ro o
M
0- o
Fj- tR
_
o
r-
V
=
Z
o
a
U
w
cc G- NA THIOSULFATE
SAMPLE LOCATION
DATE
TIME
5W #1 Out.,Grah
1I-`4-10
oc(:4S
jL.S
6
v
�.
CLASSIFICATION:
WASTEWATER(NPDES)
SW #3 Out..Grab
�2d
����
��•�
6
z>z
Ski „ u 4 Out -Grab
1-h+2o
O 9'•3�
t�1.3
6
>'J'
DR(NKING WATER
DWRJGW
SOLID WASTE SECTION
CHAIN OF CUSTODY (SEAL) MAINTAINED
DUMNG SHIPMENT/DELIVERY
Y N
SAMPLES COLLECTED BY:
((Pl]ease Prins)
SAMPLES RECEIVED IN LAB AT -C
R NOLIIISHED BY (SIG.) (SAMPLER)
DATE nME
RECE (SI .1
D TEfTIME
COMMENTS:
TY
REUNIOUISHED BY (SIG.)
DATEr nmE
REC IVEu Y (SI .}
DATEMME
RELINQUISHED BY (SIG.)
DATEITIME
RECEIVED BY (SIG.)
DATE, FIME
PLEASE READ Instructions for completing this form on the reverse side. Sampler must place a "C' for composite sample or a "G" for At
Foati, 25 Grab sample in the blocks above for each parameter requested. f � P 375557

Avoca, LLC
Po Box 129
841 Avoca Farm Rd
Avoca, LLC Merry Hill, NC 27957
Phone: [phone]
The World's Premier Botanical Extraction Company Fax: [phone]
Date: January 31, 2019
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Avoca, LLC - Permit No. NCS000134 - Bertie County
1) Stormwater Discharge Outfall Monitoring Report
2) Stormwater Discharge Outfall Qualitative Monitoring Reports
Report for July - December 2019
The storm water samples were collected during the first rainfall event in ,January
for the December sampling because there was no representative event that occurred
in December during a time period that the samples could be analyzed.
Enclosed you will find the original and 1 copy of the compliance reports on forms SWU-
246 and S WU-242 as required by Permit No. NCS000134. These reports are required
semi-annually for the period from January -June and July — December.
It should be noted that one of the benchmark values was exceeded with these
samples. The following benchmark was exceeded:
The COD benchmark is 120 mg/L. The result from Outfall 001 was 167
mg/L.
Avoca, LLC. has followed the Tier 1 and Tier 2 programs outlined in the permit to
investigate the causes for exceeding the benchmarks. It has been determined that the
benchmarks have been exceeded due to the increases amounts of sage material that are
present in the run-off to outfall 003. Avoca began monitoring outfall 003 monthly in
January 2013 due to past samples exceeding the benchmarks for both TSS and COD.
Samples have been collected, analyzed, and the results have been submitted monthly to
NCDENR. The COD has been reduced this month.

If you have any questions, please contact me at [phone] extension 287.
Sincerely,
i
Brian Conner
Environmental, Health, & Safety Manager.
Avoca, LLC

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING. REPORT
Permit Number NCS 000 t 3 Ll
FACILITY NAME AV C4 1^ L
PERSON COLLECTING SAMPLE(S)
CERTIFIED LABORATORY(S) t--,r v "' V'1Dy%VY12v-,+ A- Lab #�
Lab #
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR:
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
COUNTY 9 �4 %
PHONE NO. ('ZSZ) '49.�Z—'z 133 -
SIGNATURE OF PERNIITTEE OR DESIGNEE
REQUIRED ON PAGE 2. _j
Outfall
No.
Date
Sample
Collected
50050
Total
Flow if a
Total
Rainfall
N �st,a Cr1
L�Qd
QAoS V1oruS
ass
C—fl ID
mo/dd/ r
MG
inches
+"►� i L_
�� L
+•++q i
+r*�q i 1^
r�.g tir
Oo
Ok -t o
C. S
1
A Is
.os
O_ Ct
-b
0 77,
1.Z2.
-t0
Oo
4
0.
<4D.005
0.09
{ Z.(o
4-a0
.1b0
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes V_n
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Outfall
No.
Date
Sample
Collected
50050
'00556
00530
00400
Total Flow
(if applicable)
Total
Rainfall
Oil & Grease
(if appl.)
Non -polar
O&G/TPH
(Method 1664
SGT-HEM), if
appl.
Total
Suspended
Solids
pH
New Motor
Oil Usage
mo/dd/ r
MG
inches
m /I
m g1l
unit
al/mo
Form SWOT-247, last revised 21212012
Page 1 of 2

STORM EVENT CHARACTERISTICS:
Date �4-2
Total Event Precipitation (inches): C) .�
Event Duration (hours): Qj (only if applicable — see permit.)
(if more than one storm event was sampled)
Date
Total Event Precipitation (inches):
Event Duration (hours): (only if applicable-- see permit.)
Mail Original and one copy to:
Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
"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 fines and imprisonment for knowing violations."
(Signature of Permittee) (Date)
Form SWU-247, last revised 21212012
Page 2 of 2

NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling out this form, please visit: htt ortal.ncdenr.or weU 11r n p des-stormwater/
Permit No.: N/C/ a/O/O/1/.3/-q/_/ or Certificate of Coverage No.:
Facility Name: l4•409A 3 Inc or��ra�E r�
County: 'bev
Phone No. ZSZ- LA'aZ- 2133
Inspector:. L�a,.�. C►rwav _ _
Date of Inspection: A71yr Z.O
Time of Inspection: O'k'.K5
Total Event Precipitation (inches): D
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
Yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "meosureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions, if applicable.
A "representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 1.0 consecutive hours of no
precipitation.
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 DWQ 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)
Pagel of 2
SWU-242, Last modified 7/31/2013

1. Outfall Description: (�
Outfall No. -!._. Structure (pipe, ditch, etc.) ` i �-
Receiving Stream: SGA""'on creek
Describe the industrial activities that occur -within the outfall drainage area:
Rniarl%Ca, Q�'Srca[,�seA�► Q� �osv�av�n4S, Q, c��Vi�S, �rCxQraxtC2S� Cisie'�aY�t S�t�n1��M4A'�i$
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: C_IQav
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): _ W Ong
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy: .
U 1 2 3 4 5
S. 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:
Q2 3 4 5
7. Is there any foam in the stormwater discharge? Yes No
8. Is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
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 7/31/2013

��, AY-
MCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this form, please visit: http://portalmcdennorg/web/Ir/npdes-stormwater/
Permit No.: N/C/ 4/4/ O/1/_3/'�/_/ or Certificate of Coverage No.:
Facility Name: IAVDCA nc.O,FDlra�i1,
County: Ze_Ae. Phone No.
Inspector..,,,Nr,6A Arnim.
Date of Inspection: HLA-10
Time of Inspection: �O%00
Total Event Precipitation (inches). d
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
M/Yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit.
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions, if applicable.
A "representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and -that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
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 DWQ 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)
Page 1 of 2
SWU-242, last modified 7/31/2013

I. Outfall Description:
0utfall No. Q M. Structure (pipe, ditch, etc.)
Receiving Stream: S6AIrcorl Creek
Describe the industrial activities that occur. within the outfaalI drainage area:
C 5
2. Color: Describe the color of the discharge using basic colors (red, brown, brae, etc.) and tint
(light, medium., dark) as descriptors: �.-C'\Cr',
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): c�
4. Clarity: Choose the number which best describes the clarity of the discharge, where I is
clear and 5 is very cloudy; .
Ll/ 2 3 4 5
5. Floating Solids: Choose the number which best describes the amount of floating solids in
the stormwater discharge, where I 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 I is no solids and 5 is extremely muddy:
G 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes
B. Is there an oil sheen in the stormwater discharge? Yes No
9. is there evidence of erosion or deposition at the outfall? Yes No
10. Other Obvious Indicators of Stormwater Pollution:
List and describe
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
SW[7-242, Last modified 7/31/2013

NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling outthisform, please visit: http//portal.ncdenr.ore/web/Ir/npdes-stormwater4
Permit No.: N/C/ 0/O/ 0/-L/3/-q/_/ or Certificate of Coverage No.: N/C/G/_.1-1—/._/_/_/
Facility Name:
County: ZCv
Inspector. 3
Phone No. Z52-- 4Z>Z- Z,1'3'2
Date of Inspection: j-„ _
Time of Inspection: 10 ' OS
Total Event Precipitation (inches): © • l
Was this a "Representative Storm Event" or "Measureable Storm Eveni" as defined by the permit?
(See information below.)
Vyes ❑ No
,Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions, if applicable.
A "representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
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 DWQ 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)
Page 1 of 2
5WU-242, Last modified 7/31/2013

1. Outfall Description:
Outfall No. �? Q Structure (pipe, ditch, etc.)
Receiving Stream: SGA"'C)'n Cree k
Describe the industrial activities that occur within the outfall drainage area:
QrtaCqk- Q��*ce4�s49r► O T ���y0l�y�g5��+i�V@S.r[�Qm��C2S,� C}iie'�n�o►g Su$"d�eC�h'4�
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: �-"AbA QV'RS
3. Odor; Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): W ov%e,
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy: .
Q 3 4 5
S. 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:
0 2 3 4 5
6. Suspended Solids. Choose the number which best describes the amount of suspended
solids in the stormwater discharge, where I is no solids and 5 is extremely muddy:
01 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes
B. Is there an oil sheen in the stormwater discharge? Yes N�o
9. Is there evidence of erosion or deposition at the outfall? Yes
10. Other Obvious Indicators ofStormwater Pollution:
List and describe
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
SWO-242, Last modified 7/31/2013

Flwj
NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
Forguidance on filling out this form, please visit. hLW://portal.ncdenr.org/web/­Ir/­nj)des-stQrmwater/
Permit No.: N/C/ D/D/ Q/1/ / /_/ or Certificate of Coverage No.: NXIG/_/_/_/,..,_/`/_/
Facility Name: Rya A4nc.0r ci
County: Ze..v'��e. Phone No. ZSZ- LA bZ- 2133
Inspector:
Date of Inspection: �-\W AO
Time of Inspection: (Wk - '25 0
Total Event Precipitation (inches): 0
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions, if applicable.
A "representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
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 DWQ 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)
Page 1 of 2
SWU-242, Last modified 7/31/2013

1. Outfall Description: c(�
Outfall No. �� Structure (pipe, ditch, etc.) i �e� zoc� 1)� n
Receiving Stream: SCAM"''' cy-e.e k
Describe the industrial activities that occur. within the outfall drainage area:
2. Color: Describe the color of the discharge using basic colors Cred, brown, blue, etc.) and tint
(light, medium, dark) as descriptors: (.\ s?a✓
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): !J 0
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy:.
Q 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:
0 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:
O2 3 4 5
7. Is there any foam in the stormwater discharge? Yes G
8. Is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes (N)o
10. Other Obvious Indicators of Stormwater Pollution:
.List and describe
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
5WU-242, Last modified 7/31/2013

NCDENR
Stormwater Discharge Outfall (SDO)
Qualitative Monitoring Report
For guidance on filling out this form, please visit. http//Mortal.ncdenr.org/web/irZnpdes-sto.rmwater/
Permit No.: N/C/ 4/D/ O/�///_/ or Certificate of Coverage No.:
Facility Name:
County: Zew
Inspector:
Phone No. Z.SZ- LA bZ.- Z133
Date of Inspection: \—Wk-20 _
Time of Inspection: ION 20
Total Event Precipitation (inches): d •1
Was this a "Representative Storm Event" or "Measureable Storm Event" as defined by the permit?
(See information below.)
[(Yes ❑ No
Please verify whether Qualitative Monitoring must be performed during a "representative storm
event" or "measureable storm event" (requirements vary, depending on the permit).
Qualitative monitoring requirements vary. Most permits require qualitative monitoring to be
performed during a "representative storm event" or during a "measureable storm event." However,
some permits do not have this requirement. Please refer to these definitions, if applicable.
A "representative storm event" is a storm event that measures greater than 0.1 inches of rainfall
and that is preceded by at least 72 hours (3 days) in which no storm event measuring greater than
0.1 inches has occurred. A single storm event may contain up to 10 consecutive hours of no
precipitation.
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 DWQ 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)
Pagel of 2
SW'U-242, Last modified 7/31/2013

1. Outfall Description:
OutfalI No. 00-7 Structure (pipe, ditch, etc.)
Receiving Stream: SdAl', sin Creek
Describe the industrial activities that occur within the outfall drainage area:
vi G l si�iera��s�` vs O� '��QV'Ocr+r'� S '�Ci`1C�5 �r rQ C� s4' ie.�aV v �^►W1, �
2. Color: Describe the color of the discharge using basic colors (red, brown, blue, etc.) and tint
(Iight, medium, dark) as descriptors: C,\euv w
3. Odor: Describe any distinct odors that the discharge may have (i.e., smells strongly of oil,
weak chlorine odor, etc.): W o'
4. Clarity: Choose the number which best describes the clarity of the discharge, where 1 is
clear and 5 is very cloudy: -
�1 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:
O2 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:
O1 2 3 4 5
7. Is there any foam in the stormwater discharge? Yes
8. Is there an oil sheen in the stormwater discharge? Yes No
9. Is there evidence of erosion or deposition at the outfall? Yes
10. Other Obvious Indicators of Stormwater Pollution:
Dist and describe
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 7/31/2013

Ii-EWC-27858
AVOCA, LLC (STORMWATER SITES)
MR. BRIAN CONNER
P.O. BOX 129
MERRY HILT, ,NC 27957
PARAMETERS
PH (not to be used for reporting)
COD, mg/l
Total Suspended Residue, mg/I
Total Igeldahl Nitrogen as N,mgll
Total Kjeldahl Nitrogen as N,mg/l
Nitrate -Nitrite as N, 111911
Total Phosphorus as P, mg/l
Lead, ug/i
Lead, ug/I
ID#: 605
DATE COLLECTED: 01/14/20
DATE REPORTED : 01/30/20
REVIEWED
BY: .
SW #1
S«' N3
SW N4
Allalysk
Method
Otit.,Grab
Out.,Grab
Out.,Grab
Date Analyst
Code
7.2
7.3
6.8
01/15/20
GNB
4500HB-I1
167
so
<20
01/16/20
KDS
H8000-79
59
70
<2.6
01/16/20
1110
254OD-11
1.20
0.50
01/23/20
AKS
351.2 R2-93
2.64
01/17/20
TLH
351.2 R2-93
0.33
0.20
0.16
01/16/20
DTL
353.2 R2-93
0.54
1.22
0.09
01/23/20
TLH
365.4-74
<5.0
7
01/23/20
NITM
311311-10
<5.0
01/29/20
NITM
3113B-10

Environment 1.Inc- CHAIN OF CUSTODY RECORD
P.O. Box 7085. 114 Oaf:inont Dr. Page I of i
C-:ra•-•nv�llsr Nf�'77R53
envirwiment I inc.com
DISINFE.CTION
CHLORINE NEl1TRALIZEDATCOLLECTION
Phone [phone] • Fax [phone]
CHLORtrIE
CLIENT: 605 Week: i
�4
�
�_q_�
Z
-
pH CHECK (LAB)
U `
Lj
P
P
P
P
P
P
CONTAINER _1YPE,PIG
.VOCA, LLC (STORMWATER SITES)
NONEp
IR. BRIAiN CONTNER
GHEMICALPRESERVATi{}N+
.0. BOX 129
TERRY HILL NC 27957
A
C
A
C
C
C
A
A -NONE D-NA0H
o
:52} 482-2133
z�
w
t B-HNO, E-HCL
D
w
a
z
y
w C- HMSO, F- ZINC ACETATE/NAOH
COLLECTION
a
¢
o
T
p
U
F.
z
E:
G - NAHIOSULFATE
SAMPLE LOCATION
DATE
TIME
SW ##1 Oat. Grab:...
��1�2Q
Oct:fig-�45
IL�S
....
CLASSIFICATION:
� WASTEWATER (NPDES)
t. Gra
SW #i3 Oa b
lt+ o 2
OS
6
w.v
w
W 4 t. : a
1-1�+20
39
l'l.3
6
i:hi,
DRINKING WATER
DWRIGW
SOLID WASTE SECTION
CHAIN OF CUSTODY (SEAL) MAINTAINED
DURING SHIPMENT/DELIVERY
Y N
SAMPLES COLLECTED BY:
(Please Print)
SAMPLES RECE VED IN LAB AT - -2 `C
R NQISHEQ B SIG.) {SAMPLER)
DATEIFIME
REC BY (SI .}
j D TJTME
COMMENTS:
1-15-10 14'• do
1S` La
RELINQUISHED BY (SIG.)
DATERIME
REC IVE Y (SI .}
DATEI IME
rVELINOU€SHED BY (SIG.)
DATE[HME
RECE PIED BY (SIG.)
DATE/fIMEE
I
PEASE READ Instructions for completing this form on the reverse side. Sampler must place a "C" for composite sample or a "T for 0.�
FORA 45 Grab sample in the blocks above for each parameter requested, N2 375557