Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ster ENVIRONMENTAL SERVICES SAMPLE SUBMISSIONIFORM 8 A . iv.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH C w 48 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev.1/96) (ple Type (circle one): /1. Potable 3. Non Potable Treated Bottle _________ 2. Non Potable 4. Other _____________________ Chain of Custody? yes no /H2000S0Al Time/Date Collected: _ Comments: Collected By: _ —S/tGA Agency Code: PWS#:_______ Source ID: .Type Descriptor: Collected From: Bill to: Location’s/ndividuals Name _ _Ao Name/Company Street_____ ______________________________________ Street________ City/St/Zip___________________ ______________________ City/St/Zip_____ Identification of Source _ _______ ;______________________ Phone#:______ Fax#: Collection Point_________ _ __________________________ CA.CH, Bl? Check#: Amount$

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:_____________________ Lab#:________ _ (circle tests) (circle tests) / / fl/ 1. Heterotrophic Plate Count (hemodialysis & an others) 2. Coliform P/A (public supplies) 2a Trihalomethanes(524) Volatile Halocarbons (524) Volatile Aromatics (524) 1. Purgeable Halocarbons (624/8260) 2. Purgeable Aromatics (624/8260) 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4. Fecal Coilform (an samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic 6. Pesticides (507) 6. PCB's (Arochlors) (608/8081) 6. Macroscopic CPesticides/PCB screen (508) 7. Methoprene (616) 7.API 8. PCB as Decachlorobiphenyi (508A) 8. Herbicides (EPA1978/8151) ___ ______ 9. Herbicides (515) 9. Pesticides (SM18/6630) Refrigerated? yes no (10 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 CaCOs 40. Antimony 60. Selenium 3. pH 22. Bromide 41. Arsenic 61. Silver 4. Conductivity 23. Bromate/Chiorate/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 TCLP 15 Solids, Suspended 34. Phosphorus Total as P 53.Lead 71 TCLP-Metals Csolids, Total 35. Phosphorus, Ortho as P 54 Magnesium 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 55 Manganese 73.TCLP-Herbicides 37. Surfactants 56. Mercury 18. Solids, Total Volatile 19. Other:________________ 38. UV254 57 Molybdenum 74. TCLP-Volatiles 75. TCLP-BNA’s 58. Nickel

NYC-WTC_000026061