Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM estcliooe WESTCHESTER COUNTY LABORATORIES AND RESEARCH eegovcm ■I 22011102 Dana Road,914Valh5935 New York 10595 al a,575 1 NYS-ELAP No. 10108

-Sample 4_____ me/Date Set:

Type (circle one): hk/s M6—H 009.5737578,0/* - Form A-70 (rev. 1/96)

("2: e7‘/ kan6 c -*/& , oMc & 77 ,/7> t 4/0, 293- P < 1 Potable.) 3. Non Potable Treated Bottle #‘s: 59, ...- .1________ _ _ _ _____ _ ________ ____

2. Non Potable 4. Other Chain of Custody? ... _ yes.. _ no Time/Date Collected; -__ 9/a/os__ _ Comments:___ Collected By: _.. 2.. ___ ____ Agency Code: PWS #;_______ Source ID: Type Descriptor:....... * Collected From * Bill to:

"sName- Location’s/ ndividual’s , C ""=== A )e r Name/Company Street __ _ _ (VAAC L_ LLA.. . Street

City/St/Zip _iks //9... _ ■ 4/07 S City/St/Zip - Identification of Source Phone#: Fax#: _ Collection Point.. _ALX CA.CH, Bl? .... Check#; _ Amounts — BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTANLESOLID ANALYSES j Lab#: _.. __ _______ _______ ___ Lab#: (circle tests) (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) . ‘2, Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) (-3, Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, sip) 4. Total Trihalomethane Potential (510) -4. Phthalales (625/8270) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5,-Organochlorine Pesticides (608/8081) 5 Microscopic 6. Pesticides (507) 6, PCB’s (Arochlors) (608/8081) /acroscopic ‘7.Pesticides/PCB screen (508) 7. Methoprene (616)

74 8.mer__ ____- -.. ..... .. ... Ii ;. P: otoe ii 9. Herbicides (515) 8. Herbicides (EPA1978/8151) 9. Pesticides (SM18/6630) ■ / 10 Pesticides (525) Refrigerated? -... _ yes... _ no

Chlorinated:? _.. _ yes no 11 Carbamate Pesticides (531) 12. Glyphosate (547) 11. Glycols hrsh 10. Petroleum Hydrocarbon Scan (310-13)

12. Acid Extractables (625/8270) 13. Diquat (549) 13. Base Neutral Extractables (625/8270) Free Chlorine Res: ...... ... .... mg/L 14. Chlorination Disinfection Byproducts (551) 14. GC/MS Semivolatile Unknown Scan Total Chlorine Res: _ mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 16. Pesticides (SM18/6630) . 16. Purgeable Aromatics (DEF) ; ci 17. Pesticides/PCB’s (DEF) i PH _.. 17. Petroleum/Hydrocarbon Scan (310-13)

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color ae 20. Acidity — . yok 18. Other:_ _____ ____________ __ _

l 39, Aluminum 1 40. Antimony 18. Other:,

(C i 59. Potassium ; 2. Turbidity , 21. Alkalinity, as CaCOa 60. Selenium 3, pH a 22. Bromide 23. Bromate/Chlorate/Chlorite 41. Arsenic 42. Barium 61. Silver 4. Conductivity 62. Sodium 24. Chloride k 43. Beryllium 5. Corrosivity (temp:______ °C) 63. Thallium 6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65/ Zinc :/ : Madhr . . old .i r ■ 46 Calcium, as CaCOa 8. Carbonaceous BOD (5 day) /4 ^Calcium, Ca* ECp 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 66. Metals/CN 29. Nitrogen, Nitrate as N (48/Chromium, Total 10. Dissolved Oxygen 67. Volatiles 30. Nitrogen, Nitrite as N 49 Chromium, Hexavalent 11. Total Organic Carbon 68. Semi-violatiles 1 50.Cobalt

13. Solids, Percent (%) 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 32. 011 an Grease e" 51. Copper 33.Phenol 152. Iron* 69. Pesticides/PCB’s 70. Disk Deliverables _Solids, Settleable MMolids, Suspended 34. Phosphorus Total as P 53 Lead TCLP 71 TCLP-Metals 36.37. SulSurfactants fates pe a : ■

35. Phosphorus, Ortho as P 54 Magnesium 72.TCLP-Pesticides 18.19. SolOtherids, Totna— l Volatie 17. Solids, Total Dissolved le a 38.UV254 55 Manganese Mercury " Mids -i.- 73. TCLP-Herbicides '. 4. It • 2 Yalatre. . OHU1 558 Nickel a NYC-WTC_000026019