Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FGRM8 A I0: 4t jester WESTCHESTER COUNTY LABORATORIES AND RESEARCH Epv.com 2 Dana Road, Valhalla, New York 10595 / TREl UE (914) 593-5575 IYS-ELAP No. 10108 Time/Date Set: orm 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 Time/Date Collected: _ 9/19/200/ //‘S6 An Comments: Collected By: SAM-71 Agency Code: _ Source ID: .Type Descriptor: Collected From: Bill to: Location’s/Individual’s Name So(s(4 Name/Company _ Street_____ ___________ Street________ City/St/Zip_____________ City/St/Zip Identification of Source Phone#:______ Fax# Collection Point CA,CH, Bl? Check#: Amounts.

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:------------ Lab#:_______ _____________ (circle tests) (circle tests) — 2 • / t 1. Heterotrophic Plate (P, Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) 3. Coliform MPN (priv well, raw, stp) c Volatile Aromatics (524) 4. Total Trihalomethane Potential (510) 3. Acrolein & Acrylonitrile (624) 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 CPesticides/PCB screen (508) 7. Methoprene (616) 7. API 8. PCB as Decachlorobiphenyl (508A) 8. Herbicides (EPA1978/8151) _ ________________________ 9. Herbicides (515) 9. Pesticides (SM18/6630) Reigerated?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 CaCOs 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.Metais/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 Golids, Total 35. Phosphorus, Ortho as P 54 Magnesium 72. TCLP-Pesticides 19. 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 75.TCLP-BNA‘s 58. Nickel

NYC-WTC_000026063