Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM SI ■ov.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 me/Date Set: Form A-70 (rev. 1/96) — nmlA2Hda450087 . Sample Type (circle one): 012,904409 61 4 * (olc k) 2///F6, 1. Potable 3. Non Potable Treated Bottle #‘s: ____ __ __ _ ________ -....._ —==-= == =========!/ o—r—RRa*==========v===*==V=========V===============lnpynenmmmmd9; 2.Non Potable 4. Other_______ ___ ____________ ___ _ _.. . Chain of Custody? .... .. yes___ no Time/Date Collected: _5____ 1110 D L....... ................. ............ Comments: _ /CDy Agency Code:__________ _ PWS#: Collected By: Source ID:_ __ _Type Descriptor: _ ee Collected From: Bil to: 0 Location’s/Individual’s Name DU ......... Dez.................... .......... Name/Company $ Street Citv/St/Zi CALF hrec ________ - 0/2a/ 40 . ...................... ... ........ . Street City/St/Zip_ 8 /// Identification of Source................. ..... . ... —..... . .. -______________ - Phone#; —— Fax#: Collection Point CKO 6 (let)9 ■

CA,CH, BI? — Check#: -_________ Amounts____ ..........

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#: _ ---------- - ---- ---------------- Lab#:______ _ - (circle tests) (circle tests) C — I ‘ 65 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 (privwell, raw, stp) -4. Total Trihalomethane Potential (510) -4. Phthalates (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) Macroscopic 67) Pesticides/PCB screen (508) 7: Methoprene (616) AR ‘-8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) 8.0er_ ____ 9. Herbicides (515) 10) Pesticides (525) 9. Pesticides (SM18/6630) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated?____ yes____ no (—11. Carbamate Pesticides (531) 11. Glycols Chlorinated:? ...... . yes__ no 12. Glyphosate (547) 12. Acid Extractables (625/8270) 13. Diquat (549) s (., "t 0 Free Chlorine Res:_ UH1 ■ 14. Chionnation Uisintection byproducts (5b 1) 14. GU/MS Semivolatiie Unknown Scan 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) Total Chlorine Res:...._____ „ mg/L 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) pH . . 17. Petroleum/Hydrocarbon Scan (310-13) 17.Pesticides/PCB‘s(DEF) 18. Other:..____ _ ________ __________ 18. Other f

EH INOltAMC ANAYS RFCULSTEC - I n (circle tests) 1. Color 2. Turbidity 3. pH 20. Acidity 21. Alkalinity, as CaCOa 22. Bromide ,39. Aluminum ) 40. Antimony j 41.-Arsenic poP /59. Potassium',- / 60. Selenium ‘ • !■. Silver 4. Conductivity 23. Bromate/Chlorate/Chlorite ; 42; Barium 62, Sodium 24. Chloride i 43. Beryllium 63 Thallium 5. Corrosivity (temp:.... ..... °C) 6. BOD (5 day) 25. Cyanide 26. Fluoride 44. Boron 45/Cadmium Ct Ver ihm 65. Zinc 7. Soluble BOD (5 day) 27. Hardness, Total as CaCOa 46- Calcium, as CaCOa 'ftP 8. Carbonaceous BOD (5 day) 28. Nitrogen, Ammonia as N /47\Calcium, Ca*2 66. Metals/CN 9. Chemical Oxygen Demand 29. Nitrogen, Nitrate as N ! 48,Chromium, Total 10. Dissolved Oxygen 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49 Chromium, Hexavalent 68. Semi-violatiles 31. Nitrogen, Total Kjeldahl as N (50 Cobalt 12. Total Organic Halides 69. Pesticides/PCB’s 13, Solids, Percent (%) 32. Oil an Grease /51 Copper 70. Disk Deliverables 33. Phenol i 52Iron . Solids, Settleable ts -i . : it.-' 34. Phosphorus Total as P i 53/Lead TCLP 71 .TCLP-Metals 18Solids, Total 35. Phosphorus, Ortho as P j 54 Magnesium / 0!* tale, 17. Solids, Total Dissolved 36. Sulfates 55.Manganese

Solids, TotA— 18. Other al Volatile - 37, Surfactants _ 56 Mercury j ; Cl ! ■ i it, ts ,-i. । Ci PYoraior 19. d I 38.UV254 57 Molybdenum adaozom St Naiai . , ( PHNA .

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