Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM Vestcl isle WESTCHESTER COUNTY LABORATORIES AND RESEARCH ieegovcom 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108

-0----------me/Date Set: mf-/5M.6-H 0290. 6 7 43 758,083 - Form A-70 (rev. 1/96)

Sample Type (circle one): c2‘/ ce7co c -/& _ 6/26 ,473. 79, //, 393- p 1. Potable 3. Non Potable Treated Bottle #‘s:.. 2 7/ 29 ___ ___ _ _.................. ..........2____ —..... ...... _ ..

2. Non Potable 4. Other Chain of Custody?yes___ no Time/Date Collected; . /in /o ( Comments: Collected By: DS Agency Code: PWS*........ .......... Source ID: _Type Descriptor: 3 _ Collected From: Bill to: — Location’s/Individual’s Name A/C A Name/Company Street /? vr 74 C —le 0/, Street City/St/Zip 1 //k/©A/002 *x F— 7 9 Cit/St/Zi- Identification of Source Collection Point de P. 1 Phone*—------------ Fax#:_. CA,CH, Bl?___ ______ Check#: Amounts s1n11099-r499------=9---Aln=An9--------=--------------u-49--=-=9--A----I-----%==9-9PAI-49999=4=94===-=============================

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:___________ _ -____________ (circle tests) Lab#:_ .—£2949-2 (circle tests) /.( _ ‘ • —T..... 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 (privwoll, raw.stp) *4 Total Trihalomethane Potential (510) -4. Phthalates (625/8270) 4. Fecal Coliform (all samples) 5. Microextractables (504) 5. .Organochlorine Pesticides (608/8081) 6 Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) /acroscopic 7.esticides/PCB screen (508) 7. Methoprene (616) 7. -8 PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8. r 9. Herbicides (515) 9. Pesticides (SMI8/6630)

Refrigerated? ____yes____ no / 10.) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) -T1. Carbamate Pesticides (531) 11. Glycols . ' 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 _ mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) Total Chlorine Res: 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) pH ...... 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) : — 18. Other:_______ ____ _ ___ _ _ . ..... _..... . 18. Other:______ _ _____________ _____ _

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) — yok 1774, 1. Color 20. Acidity 39 Aluminum T 1 59) Potassium 21, Alkalinity, as CaCOs 40. Antimony 60.' Selenium 2. Turbidity 3. pH 22. Bromide 41.Arsenic 61. Silver 4. Conductivity 23. Bromate/Chlorate/Chlorite i 42. Barium 62. Sodium 5. Corrosivity (temp:..... IC) 24. Chloride 43Beryllium 63. Thallium 6. BOD (5 day) 25. Cyanide 44. Boron 641 Vanadium , 45%Cadmium 7. Soluble BOD (5 day) 26. Fluoride 27. Hardness, Total as CaCOs 46. Calcium, as CaCOs GLP 65/ Zinc 8. Carbonaceous BOD (5 day) 9. Chemical Oxygen Demand 08 Nin yon /r." : /4'A Calcium, Ca*2 66. Metals/CN 2) Nitro pt P (48/Chromium, Total 10. Dissolved Oxygen 5/ V. mf . 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 11. Total Organic Carbon 68. Semi-violatiles ) 50.Cobalt 12. Total Organic Halides -3 Solids, Percent (%) 31. Nitrogen, Total Kjeldahl as N 32. Oil an Grease 151.Copperdads 69. Pesticides/PCB’s 70. Disk Deliverables . Solids, Settleable Polids, Suspended 33. Phenol 34. Phosphorus Total as P : 52.{Iron 53 -Lead TCLP 54 Magnesium 71 TCLP-Metals 10Solids, Total 35. Phosphorus, Ortho as P 72. TOLP-Pesticides 17. Solids, Total Dissolved 18. Solids, Total Volatile 19. Other: _n?_s 37. Surfactants 36. Sulfates

38.UV254 57 Molybdenum 55 Manganese 56. Mercury 73. TCLP-Herbicides 74. TCLP-Volatiles 75. TCLP-BNA's >58; Nickel

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