Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM stcl wistol WESTCHESTER COUNTY LABORATORIES AND RESEARCH ■ / ' gcom 2 Dana Road. Valhalla, New York 10595 914 593-5575 NYS-ELAP No. 10108

0* Sample Type (circle one): amenal5hH©S-B@CM 712,7(2 (50 Form A-70 (rev. 1/96)

6.b 1*(*tK) 0/01/F8/ /40/8 1. Potable F-.. .M P’o: bjet Bottle rs: *s ,. oizu 2. Non Potable 4. Other____ Chain of Custody? 1__ yes____ no Time/Date Collected; 25 9/. Comments:______________ ____ _____ _____ _____ ______ __ ____ Collected By: 1 s D? Agency Code: PWS #: Source ID: .. ......... ... .Type Descriptor:.

Collected From; Bill to:

Location’s/Individual’s Name 2uC_ DeA . Name/Company_____ Street - —4425/ (A&E.M .4 Street City/SUZip /0 595 City/St/Zip___ Identification of Source_ Phone#: ___________ Fax#; Collection Point _Ck ' /G CA,CH, Bl? .... Check#: Amounts

Bas : iJ 2*. CCAL AUALYIS ORGANli P01A/ £ ANA5 Thlti DRCNlt NONPOIABLL/SOL ID ANA! Y35 Lab#:______ _ _______________ _ Lab#:. .......... 4 (circle tests) (circle tests) L 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, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coliform (all samples) 5. Microextractables (504) ! c. a ocholm l e r mmn i: 5. .Microscopic Macroscopic 16. Pesticides (507) e 67 Pesticides/PCB screen (508) 6. : '■ (Arodlileg.) (200ts/ 7. Methoprene (616) -8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8.Uter __ _________ ___ 9. Herbicides (515) 9. Pesticides (SM18/6630)

Refrigerated?____ yes 10.) Pesticides (525) —gd 11.GlycolsZneegg -11. Carbamate Pesticides (531) 10. Petroleum Hydrocarbon Scan (310-13)

Chlorinated:? ____ yes no 12. Glyphosate (547) 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 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) Total Chlorine Res: . mg/L 16. Pesticides (SM18/6630) , . I on ro a : xato . r : if ; . ■ 18. Other: . . __________ __ 17.Pesticides/PCB‘s(DEF) 16. Purgeable Aromatics (DEF)

18. Other:. 1

INGIRCANIC ANA IS REQUESTED - Oil- (circle? tests) 1.2. Turbidity Color 2 20. Acidity ' 21. Alkalinity, as CaCO3 39) Aluminum /40 Antimony 59. Potassium/ 60. S': : mil■ i 3.pH 22. Bromide 23. Bromate/Chlorate/Chlorite / 41! Arsenic | 42/Barium 61 Silver i 4. Conductivity ; 62 Sodium 24. Chloride 143. Beryllium 63 Thallium 5. Corrosivity (temp:____ °C) 6. BOD (5 day) 7. Soluble BOD (5 day) 25. Cyanide 26. Fluoride 44 Boron " (45/Cadmium 64. Vanadium 65. Zinc s «. r i .1* ‘1 ' ■ (‘ : 1/ f inatio a It i..-- ■ ! 28. Nitrogen, Ammonia as N 2 { as "*; • - • i 47. Calcium, Ca*2 CLP 9. Chemical Oxygen Demand 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 12. Total Organic Halides 31. Nitrogen. Total Kjeldahl as N 50 Cobalt 69. Pesticides/PCB’s / 51 Copper 13. Solids, Percent (%) aeni alat- 33. Pheno 32. Oil an Grease 20299 53 Iron— ( 52, 70. Disk Deliverables

TCLP rSolids, TotalE 16. 34. Phosphorus Total as P 35. Phosphorus, Ortho as P .Lead i 54« Magnesium 7 1 .TCLP-Metals . 36. Sulfates “38.UV254 55 Manganese 72.TCLP-Pesticides

19. other 5------ Surfactants _ 1 575658.Molybdenum 18. Sol i d s. Total Vol a til e A 37. 17. Solids, Total Dissolved Mercury 74.TCLP-Volatiles— 73. TCLP Herbicides

Nickel T A. IQJMHNno

NYC-WTC_000026020