To apply for Certification, return a single copy of this application to:

Transcription

1 STATE OF NORTH CAROLINA Application for Initial Environmental Laboratory Certification DEPARTMENT OF ENVIRONMENTAL QUALITY DIVISION OF WATER RESOURCES WASTEWATER/GROUNDWATER LABORATORY CERTIFICATION Form #100-app 2017 INSTRUCTIONS: This application is only one part of the Certification process; completing and submitting an application does not constitute Certification. Upon review of the completed application, additional clarifications and documentation may be required. Clarifications and additional requested information received in a timely manner will expedite your application process. Please complete all applicable parts of this form using a typewriter, computer, or print legibly in ink. To apply for Certification, return a single copy of this application to: DEQ/DWR Water Sciences Section Laboratory Certification Unit 1623 Mail Service Center Raleigh, NC For additional information, contact the Laboratory Certification program office: Telephone: Fax: Program Homepage: APPLICATION FEES: An applicant for initial Certification must submit to the Department of Environmental Quality, Environmental Sciences Section, a non-refundable fee of three hundred dollars ($300.00) for the evaluation and processing of each application. ANNUAL FEES: Annual Certification Fees will be calculated in accordance with 15A NCAC 2H An annual minimum fee of $ will be assessed to all Municipal, Industrial, and laboratories. Commercial laboratories must pay an annual minimum fee of $2, Do not submit annual fees until you are issued an invoice. Invoices will be issued after completion of the application process. RECIPROCITY: For reciprocal Certification, submit a copy of the current certificate, a list of accredited Fields of Testing, proficiency testing results for samples analyzed within the six months prior to this application and the most recent on-site inspection report. Reciprocity is not guaranteed, in some cases, submitted documentation may be insufficient to grant Certification by reciprocity and an on-site inspection will be performed.

2 Page 2 of 29 Section A: Facility Name: EPA Lab Code: Facility and Contact Information (If applicable) NPDES Permit Number(s): OFFICE USE ONLY CERT#: Contact Person*: Telephone #, ext. Contact Person Address: Laboratory Manager **: Telephone #, ext. Laboratory Manager Address: Laboratory Supervisor: Telephone #, ext. Laboratory Supervisor Address: Quality Assurance Officer (if applicable): Telephone #, ext. Quality Assurance Officer address: Facility Address: City State Zip Mailing Address: City State Zip County (NC applicant only): Fax Number: Billing Address: City State Zip Billing Contact Person*: Telephone #, ext. Billing Contact Person Address: * For North Carolina Wastewater/Groundwater Laboratory Certification (NC WW/GW LC) purposes, the Contact Person may also be either the Laboratory Supervisor or the Laboratory Manager. ** For NC WW/GW LC purposes, the Laboratory Manager shall be administratively above the Laboratory Supervisor (they cannot be the same person except at commercial laboratories where the owner is the laboratory supervisor and there is no one administratively above the laboratory supervisor).

3 Page 3 of 29 Section B: Laboratory Supervisor Information NOTE: An attached resume may be substituted for this section. 1. Education: List the College(s), University (ies), or Technical Institute(s) attended, dates of attendance and degree received. 2. Experience: List work-related experience, indicating the employer, years of employment, and basic job description. Also list pertinent licenses, Operator Certification and grade, etc. 3. References: List three people familiar with your professional competency, provide contact information for each in the form of a telephone number or address.

4 Page 4 of 29 Section C: Laboratory Information 1. Application Type Initial Certification Initial Certification by Reciprocity* Reciprocal State * Reciprocity will be granted for initial Certification only. Maintenance inspections may be performed by the NC WW/GW LC program. 2. Description of Laboratory (check all that apply) MUNICIPAL, INDUSTRIAL, OTHER COMMERCIAL LABORATORY (fees for analytical services) TYPES OF SAMPLES PROCESSED Municipal Wastewater Laboratory Commercial Laboratory Wastewater Effluent State/County Health Laboratory Commercial Mobile Laboratory Industrial State Laboratory Pretreatment University/Academic Laboratory Groundwater Municipal Public Water Supply Surface Waters Industrial Laboratory UST (Underground Storage Tanks) Hazardous Waste Soils/Sediment/Sludge Reclaimed Water (specify)

5 Page 5 of 29 Section D: Quality Assurance Proficiency Testing (PT) - Prior to issuance of Certification, this office must receive acceptable PT sample results from a NELAC approved provider for each of the requested parameter methods for which Certification is requested and for which PT samples are available (refer to the NC WW/GW LC website for required PTs). All testing rounds must have occurred within the six months prior to the date of application. For multi-analyte parameters (e.g., Purgeable Organics), results for all spiked components from the primary list of the target group must be reported. Alternatively, the laboratory may appeal to report an abbreviated list if they can demonstrate that the abbreviated list will be a routine reporting scheme for North Carolina client data reporting. Are PT samples for each of the requested analytical parameter methods being sent to the Laboratory Section? Yes No If not supplied, are they on order? Yes No Anticipated Completion Date Results are not supplied for the following parameter methods: Submit one copy of the Laboratory's Quality Assurance Manual, which must include the established quality control limits (where appropriate to the method) for all requested parameters. The Quality Assurance manual may also contain Standard Operating Procedures (SOPs) for each method that Certification is requested. If not, the laboratory must also submit SOPs for each parameter method requested. The Quality Assurance manual must provide a listing of major equipment used in the analytical testing process. Calculated Minimum Detection Limits (MDLs) and Initial Demonstration of Capability (IDOCs) studies for: Analytes by Ion Chromatography, Oil and Grease by EPA 1664, all Organic determinations, Inductively Coupled Plasma (ICP) and ICP-Mass Spec (ICP-MS) metals, and any other analytes for which the analytical method requires it MUST be submitted, if Certification is requested, with the completed application. MDL studies must be conducted as specified by 40 CFR Part 136, Appendix B.

6 Page 6 of 29 Section E: Analytical Methods Parameter methods for which Certification may be requested are listed below. This list is not all inclusive, but represents the parameter methods most often requested. Submit a request for additional parameter methods by writing the reference and method number in the column next to the appropriate parameter. Method Selection: Please circle each method for which you are requesting Certification and specify the lower reporting limit. If the method does not appear, you may write it in the column. Be sure to include the complete method reference and specify the desired matrix as described below. Note: For all organic analytical categories, please attach a typed list of analyte-specific lower reporting limits. Note: DO NOT provide us with the laboratory method detection limit, unless the lower reporting limit and method detection limit are the same. Matrix Specification: Methods highlighted in blue are only applicable to aqueous samples. Methods highlighted in brown are only applicable to non-aqueous samples. Simply circling the appropriate method will specify the matrix. Methods highlighted in green are applicable to both aqueous and non-aqueous samples. When selecting green highlighted methods, indicate the desired matrix in the space to the right using the following number scheme; 1 = Aqueous 2 = Non-Aqueous 3 = Both Aqueous and Non-Aqueous Inorganic Analytical Parameters Technology EPA Methods Standard Methods EPA SW-846 Acidity Titration 2320 B-1997 (Include Reference and Method No.) Limit Conc. (Include Units) Alkalinity Biochemical Oxygen Demand (BOD5) Titration 2320 B-1997 Automated 310.2, Rev D.O. Depletion 5210 B-2001 Luminescence Based Sensor 5210 B-2001 In-Situ

7 Page 7 of 29 Inorganic Analytical Parameters Technology EPA Methods Standard Methods EPA SW-846 (Include Reference and Method No.) Limit Conc. (Include Units) Bromide Carbonaceous BOD, (CBOD5) Ion Chromatography Electrode D.O. Depletion with Nitrification Inhibitor Luminescence Based Sensor , Rev. 1.0 (1997) 300.0, Rev B C D B B A ASTM D In-Situ Chemical Oxygen Demand, (COD) Titrimetric 410.3, Rev C-1997 Spectrophotometric 410.4, Rev D-1997 ASTM D (A) ASTM D (B) Hach 8000 Titrimetric (AgNO3) 4500-Cl - B Chloride Titrimetric (HgNO3) 4500-Cl - C-1997 Automated Continuous Flow IC Electrode , Rev. 1.0 (1997) 300.0, Rev Cl - E SEAL 124-A Rev B-2000 USGS I A ASTM D (C)

8 Page 8 of 29 Inorganic Analytical Parameters Technology EPA Methods Standard Methods EPA SW-846 (Include Reference and Method No.) Limit Conc. (Include Units) Chlorine, Free Available Amperometric 4500-Cl D Cl E-2000 DPD-FAS 4500-Cl F-2000 Spectrophotometric, DPD 4500-Cl G-2000 Iodometric Titration I 4500-Cl B-2000 Iodometric Titration II 4500-Cl C-2000 Amperometric Titration 4500-Cl D-2000 Hach ULR Low-Level Amperometric Titration 4500-Cl E-2000 Hach ULR Chlorine, Total Residual DPD Colorimetric 4500-Cl G-2000 DPD-FAS 4500-Cl F-2000 Hach 8167 HR Hach HR Electrode Orion Electrode, 1977 Color PtCo 2120 B-2001 ADMI 2120 E-1993 NCASI (PtCo) NCASI 253 (PtCo) Conductivity at 25ºC Wheatstone Bridge 120.1, Rev B A

9 Page 9 of 29 Inorganic Analytical Parameters Cyanide, Total Technology EPA Methods Standard Methods EPA SW-846 Titrimetric Spectrophotometric, Manual Ion Selective Electrode Manual or Semiautomated prep with (circle one): FI/Gas Diffusion Amp, Titrimetric, Spectrophotometric Automated UV digestion/distillation and Colorimetric 335.4, Rev CN - D CN - E CN - F B (Include Reference and Method No.) Lachat X Kelada-01 Limit Conc. (Include Units) Segmented Flow Injection Analysis, In- Line Ultraviolet Digestion and Amperometric Detection ASTM D Cyanide, Amenable Titrimetric Spectrophotometric 4500-CN - G D CN - G E B B 9014 Cyanide, Available FIA/Ligand Exchange Automated Distillation and Colorimetry OIA Kelada-01

10 Page 10 of 29 Inorganic Analytical Parameters Technology EPA Methods Standard Methods EPA SW-846 (Include Reference and Method No.) Limit Conc. (Include Units) Dissolved Organic Carbon (DOC) Combustion 5310 B-2000 Heated Persulfate or UV Oxidation 5310 C D-2000 Winkler 4500-O C-2001 Dissolved Oxygen (DO) Electrode 4500-O G-2001 Luminescence Based Sensor ASTM D (B) ASTM D (C) Hach In-Situ Electrode 4500-F - C Manual Colorimetric 4500-F - D-1997 Fluoride Automated 4500-F - E-1997 IC , Rev. 1.0 (1997) 300.0, Rev B A

11 Page 11 of 29 Inorganic Analytical Parameters Technology EPA Methods Standard Methods EPA SW-846 (Include Reference and Method No.) Limit Conc. (Include Units) Automated (1971) Titrimetric (EDTA) 2340 C-1997 Hardness, Total Calculation, Ca plus Mg as their carbonates - Note determinative method(s) here: Ca Mg B-1997 Ignitability Closed Cup Tester Closed-Cup Tester 1010A 1020B Powder Train 1030 MBAS as Surfactants Manual Colorimetric 5540 C-2000 Nitrogen, Ammonia Titration Electrode 4500-NH3 C NH3 D NH3 E-1997 Ion Chromatography ASTM D Automated Phenate, salicylate, or other substituted phenols in Berthelot reaction based methods 350.1, Rev NH3 G NH3 H-1997

12 Page 12 of 29 Inorganic Analytical Parameters Technology EPA Methods Standard Methods EPA SW-846 Prep Titration Electrode Electrode Manual Phenate, salicylate, or other Nitrogen, Total substituted phenols in Kjeldahl (please Berthelot reaction indicate the based methods determinative method with the Semi-Automated preparation method) Phenate Automated Phenate (No Separate Prep Method) Semi-automated block digester colorimetric (distillation not required) Digestion with peroxodisulfate, followed by Spectrophotometric (2,6-dimethyl phenol) (1) Animal Waste Nutrient Management (AWNM) , Rev (1978) 351.2, Rev Norg B Norg C NH3 C NH3 D NH3 E NH3 F NH3 G Norg D-1997 (Include Reference and Method No.) Devarda s Alloy EPA 351.2, Rev. 2.0, (1) Hach Limit Conc. (Include Units)

13 Page 13 of 29 Inorganic Analytical Parameters Technology EPA Methods Standard Methods EPA SW-846 Cadmium Reduction, Manual Cadmium Reduction, Automated 353.2, Rev NO3 - E NO3 - F-2000 (Include Reference and Method No.) EPA 353.2, Rev. 2.0, 1993 [SEAL 126-A] Limit Conc. (Include Units) Nitrogen, Nitrate-nitrite Automated Hydrazine 4500-NO3 - H-2000 IC , Rev. 1.0 (1997) 300.0, Rev B A Spectrophotometric (2,6-dimethyl phenol) Hach Colorimetric (Brucine Sulfate) (1971) Electrode 4500-NO3 - D-2000 Nitrogen, Nitrate IC Spectrophotometric (2,6-dimethylphenol) , Rev. 1.0 (1997) 300.0, Rev B A Hach Nitrate-nitrite N minus Nitrite N Note determinative methods here: Calculation NO3+NO2 NO2 -

14 Page 14 of 29 Inorganic Analytical Parameters Nitrogen, Nitrite Oil & Grease, HEM Technology EPA Methods Standard Methods EPA SW-846 Automated Bypass Cadmium Reduction Spectrophotometric: Manual Manual Bypass Cadmium Reduction IC Gravimetric 353.2, Rev , Rev. 1.0 (1997) 300.0, Rev NO3 - F-2000 (Include Reference and Method No.) ASTM D (A) 4500-NO2 - B-2000 Hach NO3 - E B A 1664 Rev. B 5520 B A 9071B ASTM D (B) Limit Conc. (Include Units) Ortho-phosphate Manual Colorimetric (1978) 4500-P E-1999 Automated IC 365.1, Rev , Rev. 1.0 (1997) 300.0, Rev P F B A Paint Filter Liquids Gravimetric 9095B ph Electrode 4500-H + B C 9045D Automated Electrode (1982) (1) Animal Waste Nutrient Management (AWNM).

15 Page 15 of 29 Inorganic Analytical Parameters Technology EPA Methods Standard Methods EPA SW-846 (Include Reference and Method No.) Limit Conc. (Include Units) Manual Colorimetric (1978) 9065 Phenols, Inorganic Automated Colorimetric 420.4, Rev Phosphorus, Total Manual Colorimetric (1978) 4500-P E-1999 Automated ICP-AES Mehlich 3 Extraction (1) (please note determinative method here): 365.1, Rev (1974) 200.7, Rev P F P G D Residue, Settleable Volumetric 2540 F-1997 Residue, Total Gravimetric 2540 B-1997 Residue, Total Dissolved Residue, Total Suspended Gravimetric 2540 C-1997 Gravimetric 2540 D-1997 Residue, Volatile Gravimetric (1971) 2540 E-1997 Salinity Electrical Conductivity 2520 B-2010 (1) Animal Waste Nutrient Management (AWNM).

16 Page 16 of 29 Inorganic Analytical Parameters Sulfate Sulfide Technology EPA Methods Standard Methods EPA SW-846 Automated Gravimetric 375.2, Rev SO4 2- C SO4 2- D-1997 (Include Reference and Method No.) Turbidimetric 4500-SO4 2- E ASTM D IC Titrimetric Manual Colorimetric , Rev. 1.0 (1997) 300.0, Rev B A 4500-S 2- F S 2- D Sulfite Titrimetric 4500 S03 2- B Limit Conc. (Include Units) Temperature Thermometric 2550 B-2000 USGS Method 1975 Total Organic Carbon, (TOC) Turbidity Combustion 5310 B A Heated Persulfate or UV Oxidation Nephelometric 180.1, Rev C A 5310 D B (1) Animal Waste Nutrient Management (AWNM).

17 Page 17 of 29 Biological Analytical Parameters Technology EPA Methods Standard Methods EPA SW-846 (Include Reference and Method No.) Limit Conc. (Include Units) Chlorophyll a Fluorometric 445.0, Rev H-2011 Spectrophotometric 446.0, Rev H-2011 Coliform, Fecal (MF) MF p.124 (2), D-1997 Coliform, Fecal (MF) Coliform, Fecal (MPN) MF MPN SM 9222 D Sludge, 24 hr. hold time p.132 (2), C E-2006 Colilert Sludge, 24 hr. hold time 1681 Sludge 24 hr. hold time Coliform, Total (MF) MF p.108 (2) 9222 B C E-2006 Sludge 24 hr. hold time Coliform, Total (MPN) MPN p.114 (2) 9221 B-2006 MPN Enterococci MPN MF 1600 ASTM D Enterolert (IDEXX) Escherichia Coliform (E. coli) MPN 9223 B-2004 Colilert (24 hr) Colilert-18 MF 1603 mcoliblue-24 MPN 1682 SM 9260 D-2007 Salmonella Kenner & Clark, MF 1974 (2) Microbiological Methods for Monitoring the Environment, Water, and Wastes, EPA/600/8-78/ US EPA.

18 Page 18 of 29 Vector Attraction Reduction (VAR) Note: Vector Attraction Reduction requirements are now covered under 15A NCAC 02T Permit Rules. The Rule pertaining to Vector Attraction Reduction requirements can be found on the Laboratory Certification website at VAR Options Available Method Reference for each: "Control of Pathogens and Vector Attraction in Sewage Sludge" - EPA/625/R-92/013 revised July 2003 Indicate with a check mark all options used by your facility. Option 1: Reduction in Volatile Solids Content Option 2: Additional Digestion of Anaerobically Digested Sewage Sludge Option 3: Additional Digestion of Aerobically Digested Sewage Sludge Option 4: Specific Oxygen Uptake Rate (SOUR) for Aerobically Digested Sewage Sludge Option 5: Aerobic Processes, Greater Than 40 C Option 6: Addition of Alkali Option 7: Moisture Reduction of Sewage Sludge Containing No Unstabilized Solids Option 8: Moisture Reduction of Sewage Sludge Containing Unstabilized Solids Option 12: Raising the ph of Domestic Septage

19 Page 19 of 29 Metals Technology EPA Methods Standard Methods Aluminum Antimony Arsenic Barium FAA 3111 D B 3111 E-1999 GFAA 3113 B-2004 Manual Colorimetric 3500-Al B FAA 3111 B B FAA Manual Colorimetric 3114 B A 3114 C As B FAA 3111 D B EPA SW- 846 (Include Reference and Method No.) Limit Conc. (Include Units)

20 Page 20 of 29 Metals Technology EPA Methods Standard Methods Beryllium Boron Cadmium Calcium FAA 3111 D B FAA 3111 B B 3111 C-1999 Manual Colorimetric 3500-Cd D FAA 3111 B B Titrimetric (EDTA) 3500-Ca B Mehlich 3 Extraction (1) (1) Animal Waste Nutrient Management (AWNM). EPA SW D (Include Reference and Method No.) Limit Conc. (Include Units)

21 Page 21 of 29 Metals Technology EPA Methods Standard Methods Chromium, Total Chromium VI Cobalt FAA 3111 B B 3111 C-1999 Manual Colorimetric 3500-Cr B EPA SW- 846 FAA 3111 C-1999 Ion Chromatography 218.6, Rev Cr C Manual Colorimetric 3500-Cr B A FAA 3111 B B 3111 C-1999 (Include Reference and Method No.) Limit Conc. (Include Units)

22 Page 22 of 29 Metals Technology EPA Methods Standard Methods Copper Iron Lead Lithium FAA 3111 B B 3111 C-1999 EPA SW- 846 Manual Colorimetric 3500-Cu B Mehlich 3 Extraction (1) 6010 D FAA 3111 B C B Manual Colorimetric FAA 3500-Fe B B B 3111 C-1999 Manual Colorimetric 3500-Pb B FAA 3111 B B 6010 D (1) Animal Waste Nutrient Management (AWNM). (Include Reference and Method No.) Limit Conc. (Include Units)

23 Page 23 of 29 Metals Technology EPA Methods Standard Methods Magnesium Manganese Mercury Molybdenum FAA 3111 B B EPA SW- 846 Mehlich 3 Extraction (1) 6010 D FAA 3111 B B Manual Colorimetric 3500-Mn B Mehlich 3 Extraction (1) 6010 D CVAA, Manual 245.1, Rev B-2009 CVAA, Automated (Issued 1974) CVAFS 245.7, Rev. 2.0 (2005) P&T/CVF 1631E 7470 A 6010 D FAA 3111 D B (1) Animal Waste Nutrient Management (AWNM) B (Include Reference and Method No.) Limit Conc. (Include Units)

24 Page 24 of 29 Metals Technology EPA Methods Standard Methods Nickel Potassium Selenium Silica EPA SW- 846 FAA 3111 B B 3111 C-1999 FAA 3111 B B Mehlich 3 Extraction (1) 6010 D FAA 3114 B C A Manual Colorimetric 4500-SiO2 C (1) Animal Waste Nutrient Management (AWNM). (Include Reference and Method No.) Limit Conc. (Include Units)

25 Page 25 of 29 Metals Technology EPA Methods Standard Methods Silver Sodium Strontium Thallium Tin FAA 3111 B B 3111 C-1999 FAA 3111 B B Mehlich 3 Extraction (1) FAA 3111 B B FAA 3111 B B GFAA (Issued 1978) 7010 FAA 3111 B B GFAA 3113 B-2004 (1) Animal Waste Nutrient Management (AWNM). EPA SW D (Include Reference and Method No.) 6010 D Limit Conc. (Include Units)

26 Page 26 of 29 Metals Technology EPA Methods Standard Methods Titanium Vanadium Zinc FAA 3111 D-1999 EPA SW D FAA 3111 D B GFAA 7010 Manual Colorimetric 3500-V B-1997 (Include Reference and Method No.) FAA 3111 B B 3111 C-1999 GFAA 7010 USGS I Manual Colorimetric 3500 Zn B Mehlich 3 Extraction (1) 6010 D Limit Conc. (Include Units) Toxicity Characteristic Leaching Procedure for Metals (TCLP) 1311 Synthetic Precipitation Leaching Procedure for Metals (SPLP) 1312 (1) Animal Waste Nutrient Management (AWNM).

27 Page 27 of 29 Organic Parameters Categories Technology EPA Methods Standard Methods Purgeable Halocarbons GC C B Purgeable Aromatics GC C B Acrolein, Acrylonitrile, Acetonitrile GC GC/MS 603 (Acrolein & Acrylonitrile) 624 (Acrolein & Acrylonitrile) EPA SW (Acetonitrile) 8031(Acrylonitrile) Organic Phenols GC B A Benzidines HPLC 605 Phthalate Esters GC A GC/MS 6410 B-2000 Nitrosamines GC A Organochlorine Pesticides GC B C B Polychlorinated Biphenyls (PCBs) GC A Polychlorinated Biphenyls (PCBs) GC/MS 6410 B-2000 Organochlorine Pesticides & PCBs GC 608 Nitroaromatics & Isophorone GC B C-2000 Nitroaromatics & Nitramines HPLC 8330A Polynuclear Aromatic Hydrocarbons HPLC B GC Haloethers GC Chlorinated Hydrocarbons GC Purgeable Organics Base/Neutral & Acid Organics GC/MS GC/MS B B 6200 B B 6410 B D (Include Reference and Method No.) Chlorinated Acid Herbicides GC B A

28 Page 28 of 29 Organic Parameters Categories Technology EPA Methods Standard Methods Organophosphorus Pesticides GC B EPA SW- 846 (Include Reference and Method No.) Nonhalogenated Volatile Organics GC 8015C N-Methylcarbamates HPLC A 1,2 - Dibromoethane (EDB) GC Total Petroleum Hydrocarbons (TPH) Gasoline Range Organics Total Petroleum Hydrocarbons (TPH) Diesel Range Organics GC GC 8015C 8015C Extractable Petroleum Hydrocarbons (EPH) Volatile Petroleum Hydrocarbons (VPH) GC GC Massachusetts Method, May 2004, rev. 1.1 Massachusetts Method, May 2004, rev. 1.1 Chlorinated Phenolics GC/MS 1653, Rev A Adsorbable Organic Halides Total Organic Halides (TOX) Adsorption/ Titration Microcoulometer/ Titration Detector 1650, Rev C 9020B Toxicity Characteristic Leaching Procedure for Organics (TCLP) Synthetic Precipitation Leaching Procedure for Organics (SPLP) Leachates 1311 Leachates 1312

29 Page 29 of 29 Section F: Authorized Signature(s) This statement certifies that the information in this application is truthful and accurate, and that the applicant is aware of all regulations regarding the requirements of NC WW/GW Laboratory Certification, 15A NCAC 2H Signature of Laboratory Manager Date Print Name Signature of Laboratory Supervisor: (First) (M.I.) (Last) Date Print Name Form#100-app 11/14/01 Revised 02/22/2017 (First) (M.I.) (Last)