Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM tchester VCOII WESTCHESTER COUNTY LABORATORIES AND RESEARCH 7 2 Dana Road, Valhalla, New York 10595 12222.(914)593-5575 NYS-ELAP No. 10108 -e/Date Set: Form A-70 (rev. 1/96)

sMpleType (circle one): 2109-F/uC PFGPPAm 034 1 ,F1%, - ,31 > ,19 197, '' 1. Potable./ 3. Non Potable Treated Bottle #‘s:__ )____ _ __ ____ _______ __ __ _ __________ . . 2. Non Potable 4. Other Chain of Custody?___ yes____ no ___ Time/Date Collected: -2.5 Comments: Collected By: l 0.2........... Agency Code:___ PWS #: __ Source ID: Type Descriptor: Collected From: Bill to: Location’s/Individual’s Name... ......... .... Name/Company

Street _ _6 LA_NC___ Street _... __ City/SUZip _ . ............. Le— 2./ _ City/St/Zip Identification of Source.—- Phone#: . Fax#: Collection Point _CAS . Let+___ b/ CA,CH, Bl? _ Check#: Amounts_

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGAP NONPOIABLNS0L H? ANALYSIS Lab#:..... ....... -__ _______ _ _____ _ (circle tests) Lab#:___ .(circle tests) 2275t 1. Heterotrophic Plate 1—Trihalomethanes (524) ’ 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) (2.4olatile 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) 5.-Organochlorine Pesticides (608/8081) - Microscopic 6. Pesticides (507) 6; PCB’s (Arochlors) (608/8081) Macroscopic / 7.Pesticides/PCB screen (508) z. Methoprene (616) 7_ 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8 er:___ ___ ____ . . . 9. Herbicides (515) 9. Pesticides (SM18/6630) F10. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated?____ yes _ h'> 11 Carbamate Pesticides (531) 1 , Glycols Chlorinated:? . ....... yes no 12. Glyphosate (547) 12. Acid Extractables (625/8270) Free Chlorine Res:._ ur:! 113. Diquat (549) __17000 14. Chlorination Disinfection Byproducts (551) 13. Base Neutral Extractables (625/8270) 14. GC/MS Semivolatile Unknown Scan 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) Total Chlorine Res: _ mg/L 16. Pesticides (SMI8/6630) 16. Purgeable Aromatics (DEF) pH _ 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF)

woloerenieg 18. Other:___ __ __________________ ___ 18. Other:

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 1. Color 20. Acidity . 21. Alkalinity, as CaCO3 39) Aluminum 40. Antimony 259. Potassium . 60. Selenium 2. Turbidity 3. pH 22. Bromide 141. Arsenic — 61. Silver 4. Conductivity 23. Bromate/Chlorate/Chlorite 42, Barium 62. Sodium 1 5. Corrosivity (temp:_ _ °C) 24. Chloride 43/ Beryllium 63. Thallium 5 6. BOD (5 day) 25. Cyanide 44. Boron 64.JVanadium 5 : 7. Soluble BOD (5 dav) 26. Fluoride (45)Cadmium 1 65/Zinc: kA 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOa (47.Calcium, Ca *2 I CLP 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 11. Total Organic Carbon 00 Niljog I. MJilna -s P 49. Chromium, Hexavalent i.;. Semi viridiec 60X obalt 011 an Grease Percent (%) Iee -33,32, Phenol ids. Settleable “.3, SSololids, 12. Total Organic Halides :1. Nite it -i . 1a i F:-. li r s s

ee Lead Zopper 51. 1 1 csir isleet I T 70. Disk Deliverables

(olids. Suspended 34. Phosphorus Total as P 52. Iron 53. ITCLP_ 71 .TCLP-Metals To. Solids, Total . 35. Phosphorus, Ortho as P 54 Magnesium 17. Solids, Total Dissolved 36. 37. Sulfates esenee. 55. Mercury _ Surfactants Manganese 72.TCLP-Pesticides 73. TCLP-Herbicides 19. Other SyTta -38.UV254 57 18. Solids, Total Volatile Molybdenum 58,NickelI 56 74. TCLP-Volatiles . Pi...

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NYC-WTC_000026021