NCS000370_COMPLETE FILE - HISTORICAL_20191204

-- -----STORMWATER DIVISION CODINGSHEET-
RESCISSIONS.
PERMIT NO.
DOC TYPE
COMPLETE FILE -HISTORICAL
DATE OF
RESCISSION
El
WYYMMDD

November 22, 2019
North Carolina Division of Water Quality
Attn: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
BRIDGESTONE AMERICAS
TIRE OPERATIONS, LLC
Wilson Plant
P.O. Box 1139
Wilson, North Carolina 27894-1139
RECEIVED
DEC, 04 2019
ct--" , + ., ,L- r' i i-fry
Dlh/r SECTION
Re: Storm water Sampling Year 10, Period 1 Analytical Results
Dear Sir or Madam:
The BATO-Wilson facility operates under National Pollutant Discharge Elimination
System (NPDES) permit number NCS000370. The permit requires semi-annual
quantitative sampling of storm water at the facility's two outfalls. The outfalls are named
by their geographic locations, South and East. Please find the analytical results and
Storm Water Outfall Discharge Monitoring Reports for the Sampling Year 10 Period 1
for the South and East outfalls in the Attachment. The samples were collected on
November 11, 2019. The analytical results were received from the laboratory via
electronic mail at BATO Wilson on November 21, 2019. As required, the original and
one copy are enclosed.
If you have any questions concerning this report, please contact Tausha Fanslau at
[phone],
Sincerely,
4_ll Norrod
Plant Manager
BATO — Wilson Plant
cc: BATO Wilson Environmental Department
p:\My Documents\Water-Stormwater\Files19

STORNIWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS 000370
FACILITY NAME Bridgestone Americas Tire Operations, LLC
PERSON COLLECTING SAMPLE(S) Tausha Fanslau
CERTIFIED LABORATORY(S) Pace Analytical
Part A: Specific Monitoring Requirements
SAMPLES COLLECTED DURING CALENDAR YEAR: 2019
(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 Wilson
PHONE NO
( 252_)246-7485
SIGNATURE OF PER.MITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Outfall _.
No
Date
Sample
Collected.
Total
'Flo�r�(if aAp+)
Total
Raka 11
ZINC ; {t) ,
_
COD
TSS.,
-6 TRH
- y
KPH
,
a "'
'm6/ddlvr�' .
1VIG , -`.
inches _
11 /Lt
MaIL-R
East
11/12/2019
0.47
0.0246
<25
4.7
< 5
6.4
South
11/12/2019
0.47
0.154
<25
48.5
5.0
6.2
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes X no
(if yes, complete Part B)
Part B: Vehicle Maintenance Activity Monitoring Requirements
Ouifall
Date -
50
500-�,�
;00556
:�,;; _QU530
'
-No 5
Sam le F-
Sa A
[Total?FIoH- _
-_Total`s.'
$Oily& Greas` a
�Nori polar '
"Total ; "
;p H
`
1 ' ' 6 1
1\ew 1liotor
Cord;
if a Ii aC ble
'(z Pp �..�
,Rainfall 3
( �f�a I: }
&GITPH
!Nuspended=� .�
r �
�UiFusage z :"
,�.:
:.
- y
Epp
s�,u�
s�Iethod1664
f
9Solids ,r
r
k
r>�
SGT-HEM), if
7 r
a.,�_
hr'
.inchEii4
iri/1
..ml
._
i.n
cat/ o�
Form SWU-247, last revised 21212012
Pagel of 2

STORM EVENT CHARACTERISTICS:
Date 11/12/2019
Total Event Precipitation (inches): 0.47
Event Duration (hours): 4.0 (only if applicable — see permit.)
(if more than one storm event was sampled)
Mail Original and one coAy 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."
Permittee)
fl��
(Date)
Form SWU-247, last revised 21212012
Page 2 of 2

aceAnalXical®
(�www.pacelehe.com
November 21, 2019
Tausha Fanslau
Bridgestone Americas
3001 Firestone Parkway
Wilson, NC 27893
RE: Project: Stormwater Sampling
Pace Project No.: 92453778
Dear Tausha Fanslau:
Pace Analytical Services, LLC
9800 KinceyAve. Suite 100
Huntersville, NC 28078
[phone]
Enclosed are the analytical results for sample(s) received by the laboratory on November 14, 2019.
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,
Amanda Payne
[e-mail]
[phone]
Project Manager
Endosures
REPORT OF LABORATORY ANALYSIS
This repot shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC,
Page 1 of 15

acmnalyii{cal
www.pacdtbt.com
CERTIFICATIONS
Project: Stormwater Sampling
Pace Project No.: 92453778
Pace Analytical Services Charlotte
Pace Analytical Services, LLC
9800 KincoyAve. Suite 100
Huntersville, NC 28078
[phone]
9800 Kincey Ave. Ste 100. Huntersville, NC 28078
South Carolina Certification #: 99006001
Louisiana/NELAP Certification # LA170028
Florida/NELAP Certification #: E87627
North Carolina Drinking Water Certification #: 37706
Kentucky UST Certification #: 84
North Carolina Field Services Certification #: 5342
Virginia/VELAP Certification #: 460221
North Carolina Wastewater Certification #: 12
Pace Analytical Services Asheville
2225 Riverside Drive, Asheville, NC 28804 North Carolina Wastewater Certification #: 40
Florida/NELAP Certification #: E87048 South Carolina Certification #: 99030001
Massachusetts Certification #: M-NCO30 VirginiaNELAP Certification #: 460222
North Carolina Drinking Water Certification #: 37712
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 15

aceAnalytical
WWW.pacalabs.com
SAMPLE ANALYTE COUNT
Pace Analytical Services, LLC
9800 KirceyAve. Suite too
HuntersvOle, NC 28078
[phone]
Project:
Pace Project No.:
Stormwater Sampling
92453778
Analytes
Lab ID
Sample ID
Method
Analysts
Reported
Laboratory
92453778001
SOUTH
EPA 1664E
HH
1
PASI-C
EPA 200.7 Rev 4A 1994
KQ
1
PASI-A
SM 254OD-2011
CJL
1
PASI-A
EPA 9040C
ECH
1
PASI-A
SM 5220D-2011
GC
1
PASI-A
92453778002
EAST
EPA 16649
HH
1
PASI-C
EPA 200.7 Rev 4.4 1994
KQ
1
PASI-A
SM 254OD-2011
CJL
1
PASI-A
EPA9040C
ECH
1
PASI-A
SM 522OD-2011
GC
1
PASI-A
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, I.I.C. Page 3 of 15

lacieAnalyfical
wvrw.pacalaha.ca I
ANALYTICAL RESULTS
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Project: Stormwater Sampling
Pace Project No.: 92453778
Sample: SOUTH Lab ID: 92453778001 Collected: 11/12/19 13:10 Received: 11/14/19 09:04 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
1664 SGT-HEM, TPH
Analytical Method: EPA 1664B
Total Petroleum Hydrocarbons
5.0 mglL 4.8 1 11/20/19 15:17
200.7 MET ICP
Analytical Method: EPA 200.7 Rev 4.4 1994 Preparation Method: EPA 200.7 Rev 4A 1994
Zinc
154 uglL 10.0 1 11/16/19 12:39 11/18/19 06:29 7440-66-6
2540D Total Suspended Solids
Analytical Method: SM 254OD-2011
Total Suspended Solids
48.5 mglL 12.5 1 11/18/19 18:56
9040 pH
Analytical Method: EPA 9040C
pH at 25 Degrees C
6.2 Std, Units 0.10 1 11/17/19 14:50 H3
5220D COD
Analytical Method: SM 5220D-2011 Preparation Method: SM 5220D-2011
Chemical Oxygen Demand
ND mglL 25.0 1 11/19/19 16:37 11/19/19 23:21
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full.
Date: 11/21/2019 08:20 AM without the written consent of Pace Analytical Services, LLC. Page 4 of 15

(�Ia'neAnalyticale
xrru.prlc1lab3X=
ANALYTICAL RESULTS
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Project: Stormwater Sampling
Pace Project No.: 92453778
Sample: EAST Lab ID: 92453778002 Collected: 11/12/19 13:30 Received: 11/14/19 09:04 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
1664 SGT-HEM, TPH
Analytical Method: EPA 1664B
Total Petroleum Hydrocarbons
ND mg/L
4.8 1 11/20/19 16:17
200.7 MET ICP
Analytical Method: EPA 200.7 Rev 4.4
1994 Preparation Method: EPA 200.7 Rev 4A 1994
Zinc
24.6 uglL
10.0 1 11/16/19 12:39 11/18/19 06:33 7440-66-6
2540D Total Suspended Solids
Analytical Method: SM 254OD-2011
Total Suspended Solids
4.7 mg/L
2.5 1 11/18/19 18:57
9040 pH
Analytical Method: EPA 9040C
pH at 25 Degrees C
6.4 Std. Units
0.10 1 11/17/19 14:55 H3
52200 COD
Analytical Method: SM 5220D-2011
Preparation Method: SM 5220D-2011
Chemical Oxygen Demand
ND mg/L
25.0 1 11/19/19 16:37 11/19/19 23:21
REPORT OF LABORATORY ANALYSIS
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Date: 11/21/2019 08:20 AM without the written consent of Pace Analytical Services, LLC. Page 5 of 15

to
aceAnalytical
xr+P.pacil,111 .cons
QUALITY CONTROL DATA
Project: Stormwater Sampling
Pace Project No.: 92453778
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
OC Batch: 510729 -
Analysis Method:
EPA 1664E
QC Batch Method: EPA 16646
Analysis Description:
1664 SGT-HEM,
TPH
Associated Lab Samples: 92453778001, 92453778002
LABORATORY CONTROL SAMPLE:
2739945
Spike LCS
LCS
% Rec
Parameter
Units
Conc. Result
% Rec
Limits
Qualifiers
Total Petroleum Hydrocarbons
mg/L
20 22.1
110
64-132
MATRIX SPIKE SAMPLE:
2739946
35510490004 Spike
MS
MS
% Rec
Parameter
Units
Result Conc.
Result
% Rec
Limits Qualifiers
Total Petroleum Hydrocarbons
mg/L
51.4 19.6
88.9
192
64-132 M1
Results presented on this page are in the units Indicated by the "Units" column except where an alternate unit is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
Date: 11/2112019 08:20 AM without the written consent of Pace Analytical Services, LLC. Page 6 of 15

IeAnalytical
www.pacidibi am
Project: Stormwater Sampling
Pace Project No.: 92453778
QC Batch: 509903
QC Batch Method: EPA 200.7 Rev 4.4 1994
Associated Lab Samples: 92453778001, 92453778002
METHOD BLANK: 2736512
Associated Lab Samples: 92453778001, 92453778002
Parameter Units
Zinc uglL
LABORATORY CONTROL SAMPLE: 2736513
Parameter Units
Zinc uglL
Pace Analytical Services, LLG
9800 KinceyAve. Suite 100
Huntersville, NC 28078
[phone]
QUALITY CONTROL DATA
Analysis Method: EPA 200.7 Rev 4.4 1994
Analysis Description: 200.7 MET
Matrix: Water
Blank Reporting
Result Limit Analyzed Qualifiers
ND 10.0 11/18/19 05:07
Spike LCS LCS % Rec
Cone. Result % Rec Limits Qualifiers
500 478 96 85-115
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2736514 2736515
MS MSD
92452973001 Spike Spike MS MSD MS MSD % Rec
Parameter Units Result Conc. Cone. Result Result % Rec % Rec Limits RPD Qual
Zinc uglL 153 500 500 619 640 93 97 70-130 3
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2736516 2736517
MS MSD
92453397008 Spike Spike MS MSD MS MSD % Rec
Parameter Units Result Conc. Conc. Result Result % Rec % Rec Limits RPD Qual
Zinc uglL 0.23 500 500 ' 733 715 101 98 70-130 2
mg/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: 11/21/2019 0820 AM without the written consent of Pace Analytical Services, LLC.
Page 7 of 15

aceAnalytical
wwrr.paedrtbs.citrs
QUALITY CONTROL DATA
Project: Sturmwater Sampling
Pace Project No.: 92453778
QC Batch: 510251 Analysis Method: SM 2540D•2011
QC Batch Method: SM 2540D-2011 Analysis Description: 2540D Total Suspended Solids
Associated Lab Samples: 92453778001, 92453778002
METHOD BLANK: 2737978 Matrix: Water
Associated Lab Samples: 92453778001, 92453778002
Blank Reporting
Parameter Units Result Limit Analyzed Qualifiers
Total Suspended Solids mg/L ND 2.5 11/18/19 18:51
Pace Analytical Services, LLG
9800 KinceyAve. Suite 100
Huntersville, NC 28078
[phone]
LABORATORY CONTROL SAMPLE: 2737979
Spike LCS LCS % Rec
Parameter Units Conc. Result % Rec Limits Qualifiers
Total Suspended Solids mg1L 250 234 94 90-110
SAMPLE DUPLICATE: 2737980
92453632001 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg1L 44.9 51.7 14
SAMPLE DUPLICATE: 2737981
92453776004 Dup
Parameter Units Result Result RPD Qualifiers
Total Suspended Solids mg/L 40.2 39.4 2
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: 11/2112019 08:20 AM without the written consent of Pace Analytical Services, LLC. Page 8 of 15

(�15'neAnalyficalo
www.pacttlah.com
QUALITY CONTROL DATA
Project: Stormwater Sampling
Pace Project No.: 92453778
QC Batch: 509994 Analysis Method: EPA 9040C
QC Batch Method: EPA 9040C Analysis Description: 9040 pH
Associated Lab Samples: 92453778001, 92453778002
SAMPLE DUPLICATE: 2736835
92452727001 Dup
Parameter Units Result Result RPD Qualifiers
pH at 25 Degrees C Std. Units 7.9 7.7 2 H3
SAMPLE DUPLICATE: 2736836
Parameter
pH at 25 Degrees C
92453279001 Dup
Units Result Result
Std, Units 5.9 5.4
RPD Qualifiers
8 H3
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
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: 11/21/2019 08:20 AM without the written consent of Pace Analytical Services, LI-C.
Page 9 of 15

Pace Analytical Services, LLC
aeeAnalytical ® 9800 Kincey Ave. Suite 100
Huntersville, NC 28078
xww•P+tuatss.ton [phone]
QUALITY CONTROL DATA
Project: Stormwater Sampling
Pace Project No.: 92453778
QC Batch: 510477
Analysis Method: SM 5220D-2011
QC Batch Method: SM 5220D-2011
Analysis Description: 52201) COD
Associated Lab Samples: 92453778001, 92453778002
METHOD BLANK: 2738904
Matrix: Water
Associated Lab Samples: 92453778001, 92453778002
Blank
Reporting
Parameter Units
Result
Limit
Analyzed
Qualifiers
Chemical Oxygen Demand mg1L
ND 25.0
11/19/19 23:16
LABORATORY CONTROL SAMPLE: 2736905
Spike
LCS
LCS % Rec
Parameter Units
Conc.
Result
% Rec Limits
Qualifiers
Chemical Oxygen Demand mglL
750
757
101 90-110
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2738906
2738907
MS
MSD
92453323001
Spike
Spike MS
MSD MS
MSD
% Rec
Parameter Units Result
Conc.
Conc. Result
Result % Rec
% Rec
Limits RPD Qual
Chemical Oxygen Demand mglL ND
100
100 106
103 143
101
90-110 2
MATRIX SPIKE & MATRIX SPIKE DUPLICATE: 2738908
2738909
MS
MSD
92453776001
Spike
Spike MS
MSD MS
MSD
% Rec
Parameter Units Result
Conc.
Conc. Result
Result % Rec
% Rec
Limits RPD Qual
Chemical Oxygen Demand mg1L 327
100
100 444
444 118
118
90-110 0 M1
Results presented on this page are in the units Indicated by the "Units" column except where an alternate unit Is presented to the right of the result.
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full.
Date: 11121l2019 08:20 AM without the written consent of Pace Analytical Services, LLC.
Page 10 of 15

aceAnalyticalm
www.pscdsbs,com
QUALIFIERS
Project: Stormwater Sampling
Pace Project No.: 92453778
I014SI:iifro] :l-'3
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.
Pace Analytical Services, LLC
9800 KinceyAve. Suite 100
Huntersville, NC 28078
(704)B75-9092
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.
TN - The NELAC Institute.
LABORATORIES
PASI-A Pace Analytical Services - Asheville
PASI-C Pace Analytical Services - Charlotte
ANALYTE QUALIFIERS
H3 Sample was received or analysis requested beyond the recognized method holding time.
Mi Matrix spike recovery exceeded QC limits. Batch accepted based on laboratory control sample (LCS) recovery.
REPORT OF LABORATORY ANALYSIS
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Date: 11121 /2019 08:20 AM without the written consent of Pace Analytical Services, I.I.C. Page 11 of 15

laceAnalytical.
www.pacalahs.cara
QUALITY CONTROL DATA CROSS REFERENCE TABLE
Project: Stormwater Sampling
Pace Project No.: 92453778
Lab ID Sample ID QC Batch Method QC Batch
92453778001
SOUTH
EPA 1664B
510729
92453778002
EAST
EPA1664B
510729
92453778001
SOUTH
EPA 200.7 Rev 4.4 1994
509903
92453778002
EAST
EPA 200.7 Rev 4.4 1994
509903
92453778001
SOUTH
SM 254OD-2011
510251
92453778002
EAST
SM 254OD-2011
510251
92453770001
SOUTH
EPA 9040C
509994
92453778002
EAST
EPA 9040C
509994
92453778001
SOUTH
SM 5220D-2011
510477
92453778002
EAST
SM 5220D-2011
510477
Date: 11121/2019 08:20 AM
REPORT OF LABORATORY ANALYSIS
This report shall not be reproduced, except in full,
without the written consent of Pace Analytical Services, LLC.
Pace Analytical Services, LLC
9800 Kincey Ave. Suite 100
Huntersville, NC 28078
[phone]
Analytical
Analytical Method Batch
EPA 200.7 Rev 4.4 1994 509934
EPA 200.7 Rev 4A 1994 509934
SM 5220D-2011
SM 5220D-2011
510531
510531
Page 12 of 15

Document Name:
Document Revised: February 7, 2018
Sample Condition Upon Rece�tjscuiiij
Page 1 of 2
Document No.:
Issuing Authority:
uii+$r4fl$�jCA�
F-CAR-a-033-Rev.06
Pace Caroilnas Quality Office
Laboratory receiving samples:
Asheville ❑ Eden❑ Greenwood ❑ Huntersville ❑ Raleigh !f Meechanicsville❑
• Client Name: i b110V 02453778
78
. PraJect Af•
Courier: Fed Ex UPS us PS — CNent ! 1110iI!
❑ Commercial JDPace [Others ' 92483778
Custody SeatPresent7 ❑Yes �ZNo• sealslntact7 []Yes QW,
Date/initla Is Person Examining Contents: W
II / /4
Packing Material: []Bubble Wrap • ❑Bubble Bag_ s Z]None ❑ other Biological Tissue Frozen?
Thermometer, ❑Yes ❑No ZN/A
AIR Gun iD: gr M� Type of ice: AWat []Blue ONana
Cooler Temp rQ 0.3 Correction Fact u ) _ C
Temp should be above freezing to 6'C
Cooler Temp Corrected ('C): ' 0.3 Qsamples out of temp criteria. Samples on Ice, cooling process
has begun
USDA Regulated Soil (® N/A, water sample)
Did samples originate In a quarantine zone within the United States: CA, NY, or SC (check maps)?
Yes No
Did samples originate from a foreign source (internationally,
Ineludlfw Hawn II and Puorm RIcn1? MYes FlNo,
Comments/Discrepant
Present?
Yes
No
N/a
1.rrived
within Hold Time?
Y.
No
NIA
2-
Eofrustodyustody
Time A,tal ls <72. hr.)?
es
No
N/A
3.
Around Tlme Re uested?
Yes
No
NIA
4.
Valume7
Yes
Ma
N A
5.
ntainers Used?JYes
ontainers Used?
es
❑Nn
EINo
❑N/A
N/A
6.
Containers Intact?
14Yes
oNo
N/A
7.
Dissolved analysis: Sam les Field Filtered?
QYei
Na
XqLA
6:
Sample Labels Match COC?
includes Date/Time/ID/Analysis Matrix:
Wes
[:]No
[]NIA
9.
Heads ace In VOA Vials (>S-6mm)?
QYes.
Na
gNJA
10.
Trip Blank Present? .
Trip Blank Custody Seals Present?
E]Yes
OYes
❑No
No
/A
/A
11.
COMMENTS/SAMPLE DISCREPANCY
Field Data Required? ❑Yes ❑No
Lot ID of split containers:
CUENTNOTiFICATION/RESOLUTION - —
Person contacted: Date/Time:
Project Manager SCURF Review:
Project Manager SRF Review:
Date:, I 1 { 4i 11� + _
Data:
I
Page 13 of 15

• I1
6
7
8
10
12
Document Name, Document Revised: February 7, 2018
An,h�� sample Condition Upon Remlpt(SCUR) Page 1 of 2
! - Ce�a1ICa� Document No.: Issuing Authority:
F CAR-CS-033-Rev.06 Pace Carolinas Qua(4 Office
"Check mark top half of box If pH and/or dechlorination Is
verified and within the acceptance range for preservation
samples:
Exceptions: VOA, Collform, TOC, Ofl and Grease, DROJW15 (water) DOC, Lift
"Bottom half of box Is to list number of bot tie
rr=
924537�78�:
Project � ; wo
PM: AP' Due Date: '11Y21/I8
CLIENT: 92-BFUSA
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Note: Whenever there Is a discrepancy affecting North Carolina compliance samples, a copy of this form WIN tie sent to the North Carolina DEHNR Certtticatlon Uttke (Le.
Out of hold, Incorrect preservative, out of temp, incorrect containers.
Page 14 of 15

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Jp CHAIN -OF -CUSTODY ! Analytical Request Document o
The Chain -of -Custody is a LEGAL DOCUMENT, All relevant fields must he completed a rately. Ln
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