Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSIONCIFORM 3 A. ster >v.com WESTCHESTER COUNTY LABORATORIES AND RESEARCH f 2 Dana Road, Valhalla, New York 10595 J (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 #’s: 2. Non Potable 4. Other _______________________ Chain of Custody? yes no 9/19/200/ Time/Date Collected: _ (047h Comments: Collected By:. VAS/LE7 _ Agency Code: PWS#:_______ Source ID: Type Descripton Collected From: — Bill to: Location’s/Individual’s Name _________________________ Name/Company Street_____ ,____________________________ _______ — Street________ City/St/Zip_________________________________________ _ Identification of Source _ _______________________________ Phone#:______ Fax#: Collection Point__ _SOSO CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:____________________ (circle tests) 2278 1. Heterotrophic Plate Count (hemodialysis & all others) 2. Coliform P/A (public supplies) 2 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 Coliform (all samples) 5. Microextractables (504) 5. Organochlorine Pesticides (608/8081) 5. Microscopic (507) 6. PCB’s (Arochlors) (608/8081) 6. Macroscopic 6.Pesticides ( Pesticides/PCB screen (508) 7. Methoprene (616) 7. API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) __________________________ 9. Herbicides (515) 9. Pesticides (SM18/6630) 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. Add 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/Chlorate/Chiorite 42. Barium 62. Sodium 5. Corrosivity (temp:__ °C) 24. Chloride 43. Beryllium 44. Boron 63. Thallium 6. BOD (5 day) 25. Cyanide 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 Colids, Total 35. Phosphorus, Ortho as P 54 Magnesium 72.TCLP-Pesticides 17. Solids, Total Dissolved 36. Sulfates 55 Manganese 37. Surfactants 56. Mercury 73. TCLP-Herbicides 18. Solids, Total Volatile 74. TCLP-Volatiles 19. Other:________________ 38. UV254 57 Molybdenum 58. Nickel 75. TCLP-BNA's

NYC-WTC_000026062