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Document / 9 pages

Chain of custody form, Sep 2001

Machine-extracted title · confidence 85%

Record documenting sample transfer and custody for the Westchester County Department of Labs & Research.

NYC-WTC_000026055–000026063

Folder label: “22773 - 22779

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Scanned page image, NYC-WTC_000026058
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NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUPMSF’SM 79 10: . i ster vcom 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 YS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.1/96) CpleType (circle one): (1Potable 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other Chain of Custody? yes no Time/Date Collected: 9.6 *9/18/200/ Comments: Collected By: 776LA0 ____ Agency Code: PWS#:_______ Source ID: .Type Descriptor: Collected From: Bill to: Location’s/Individual’s Name 4uMewd CALor V Name/Company Street________________ Street________ City/St/ZIp_____________ _ Identification of Source . Phone#: _ _____ Fax#: Collection Point 2158 CA.CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS. ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:_____________________ Lab#:----------- (circle tests) (circle tests) / / ill 1. Heterotrophic Plate Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & an others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) 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) 5. Microscopic 6. Pesticides (507) 6. PCB’s (Arochlors) (608/8081) 6. Macroscopic ()Pesticides/PCB screen (508) 7. Methoprene (616) 7. API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) Sher 9. Herbicides (515) 9. Pesticides (SM18/6630) Refrigerated? yes no (0) Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) 11. 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 Total Chlorine Res: mg/L 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) 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) 1. Color 20. Acidity 39. Aluminum 59. Potassium 2. Turbidity 21. Alkalinity, as CaCO3 40. Antimony 60. Selenium 3. pH 22. Bromide 41. Arsenic 61. Silver 4. Conductivity 23. Bromate/Chlorate/Chlorite 42. Barium 62. Sodium 5. Corrosivity (temp:. °C) 24. Chloride 43. Beryllium 63. Thallium 6. BOD (5 day) 25. Cyanide 44. Boron 64. Vanadium 7. Soluble BOD (5 day) 26. Fluoride 45. Cadmium 65. Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 46. Calcium, as CaCOs CLP 9. Chemical Oxygen Demand 28. Nitrogen, Ammonia as N 47. Calcium, Ca+2 66. Metals/CN 10. Dissolved Oxygen 29. Nitrogen, Nitrate as N 48. Chromium, Total 67. Volatiles 11. Total Organic Carbon 30. Nitrogen, Nitrite as N 49. Chromium, Hexavalent 68. Semi-violatiles 12. Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 50. Cobalt 69. Pesticides/PCB's 13. Solids, Percent (%) 32. Oil an Grease 51. Copper 70. Disk Deliverables 14. Solids, Settleable 33. Phenol 52. Iron 15-Solids, Suspended 34. Phosphorus Total as P 53 .Lead ICLP 71 TCLP-Metals Colids, Total 35. Phosphorus, Ortho as P 54 Magnesium 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 55 Manganese 73. TCLP-Herbicides 18. Solids, Total Volatile 37. Surfactants 56. Mercury 19. Other________________ 38. UV254 57 Molybdenum 74. TCLP-Volatiles 58. Nickel 75.TCLP-BNAs

NYC-WTC_000026058

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