Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

' ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM \estnld ster 9=/02i WESTCHESTER COUNTY LABORATORIES AND RESEARCH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 me/Date Set: metis MA,* 66-7 6 Form A-70 (rev. 1/96) 79-Puc ©*l i 5*8, * h, 3 > 119 (77, Sample Type (circle one): ,*/0////////1/1/11/1/01/111101/1/1 —1111——_/010007/—//1/11/111 f'r : : , t 1. Potable / 3. Non Potable Treated Bottle #‘s:___ :___ __ __ ___ _ ___ 2. Non Potable 4. Other Chain of Custody?.. ... yes....._ no Time/Date Collected: 12oS LEI 0l Comments:. Collected By:AAG__11107 . Agency Code = PWS #: Source ID: Tvbe Descriptor: Collected From: f ). _ Bill to: Location’s/Individual’s Name Aale Name/Company ___________________________ ________ Street... 167... (el. LA........ ( C _ Street .................. '................................ ........ ... ......... ■ City/St/Zip _kallkAA 105’8 City/St/Zip — iI Identification of Source....... ... Q Phone#: ------ • ill - — ____ _ Fax#; _ Collection Point CAT LP+4 U (0 3 =/ ' -= CA,CH, Bl? - --- --- Check#. _____ Amount— BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#.---------- (circle tests) Lab#: (circle tests) 4 1—T rihalomethanes (524) 1 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) ' 5. Organochlorine Pesticides (608/8081) c Microscopic 6. Pesticides (507) 6: PCB’s (Arochlors) (608/8081) acroscopic /1. Pesticides/PCB screen (508) 7: Methoprene (616) 7.8 -8. PCB as Decachlorobiphenyl (508A) 8 Herbicides (EPA1978/8151) 8.ber -__ ____ __ . 9. Herbicides (515) 9. Pesticides (SM 18/6630) 10. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated?..... . yes no *11 Carbamate Pesticides (531) 11. Glycols Chlorinated:? yes no 12. Glyphosate (547) 1 2. 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 15. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) pH _ 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 18. Other 18. Other:___

F INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) 4,/2 1. Color 20. Acidity 39. Aluminum — 1 59. Potassium 2. Turbidity 21. Alkalinity, as CaCOa 60. Selenium I 3. pH 22, Bromide 61. Silver | 4. Conductivity 23. Bromate/Chlorate/Chlorite: 42. Barium 62. Sodium' 5. Corrosivity (temp. °C) 24. Chloride \43/Beryllium 63. Thallium c _ || 6. BOD (5 dav) 25. Cyanide 44. Boron 64. Vanadium - 7. Soluble BOD (5 day) (45, Cadmium 26. Fluoride 65/ Zinc / // , 46. Calcium, as CaCOo R Camhonacenus BOD (5 dav) 27. Hardness. Total as CaCOa CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N /47Calcium, Ca 12 66. Metals/CN 10. Dissolved Oxygen 29. Nitrogen, Nitrate as N [ 48 Chromium, Total 67. Volatiles ! . (ri 1 sgot ■ 3C. Niimger, Marlo .. N 49. Chromium, Hexavalent *, : mo wah* 12. Total Organic Halides a Ntospor ldtepeidanU |50.Cobaltmm Gi Poslu rk i ’Ct" '3. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables Solids, Settleable Golids, Suspended 33. Phenol 34. Phosphorus Total as P 52. Iron 53Xead TCLPo 71 TCLP-Metals TS.Solids, Total 35. Phosphorus, Ortho as P 54 Magnesium 72.TCLP-Pesticides 17. Solids, Total Dissolved 18. Solids, Total Volatile 55 36. Sulfates 37. Surfactants Manganese 56.. Mercury 73. TCLP-Herbicides

!;•. Oftatr I (38.UV254enn 57 Molybdenum 74. TCLP-Volatiles 75.TCLP-BNA's i A mhoos

NYC-WTC_000026026