Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM \ r. 223 WEST CHESTER COUNTV 5 pppAmoPiT AMP PFerARcH 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 [ ’ ti PAi -.1/.

Sample Type (circle one): I 118C’.A 0325miBwk)] 1. PotableJ 3. Non Potable Tieated Bottle #‘s: 12 t 10,705. bovt 2. Non Potable 4. Other___________ Chain of Custody?___ yes___ no Time/Date Collected: __ Comments: — Collected By:____ i. 0 . .r _ Agency Code: _ PWS _________ Source ID: Type Descriptor: Collected From: Bill to: Location's/Individual's Name _ Name/Company___ Street _..._ - ■___ ___ ... _ _ Street__________ City/St/Zip_________ ______ City/St/Zip Identification of Source______ Phone#:. .. ........ ...... Fax#:... Collection Point___ '__ CA.CH, Bl? Check#:....________ Amounts..

AC1U8 tCAi **Al YS’S ORGANIC PUTABLE ANALYST OECA56 NONPRTAEIF/:21 ANA V« 5 Lab#:_ _ __ ____ ______ (circle tests) 1. Heterotrophic Plate Lab#:____ (circle tests) __ _ 2.2.474 (524) * 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) Je2.olatile Halocarbons (524) 2. Purgeable Aromatics’ (624/8260) 2. Coliform P/A (public supplies) ( "3.) Volatile Aromatics (524) 3. Acrolein & Acrylonitrile (624) i 3. Coliform MPN (priv well, raw, stp) 4. Total Trihalomethane Potential (510) -4. Phthalates (625/8270)

‘ Fecal Coliform (all samples) Microscopic 1495.Microextractables(504)a 14.6, Pesticides (507) end 5.*Organochlorine Pesticides (608/8081)

6. Macroscopic 110 7.Pesticides/PCB screen (508) . 7.Methoprene(616)_ 6, PCB's (Arochlors) (608/8081)

er— -9. s

C110, Herbi ciiddeses (525) ho (!A;

Pesti c (515) . ;■ i. ! . Illas (1 PAIR/0 . ! ■. ‘ide (MiM/gm

711. Carbamate Pesticides (531) - 11.Gvcols_ 10 P cun i lyiliocarbon h i (0 il; iddeppii..... v* no Chlorinated:? ___ yes___ no 12. Glyphosate (547) 12. Acid Extractables (625/8270) nd/ Free Chlorine Res:... mg/L 11113. Diquat (549) 1 14. Chlorination Disinfection Byproducts (551) 13. Base Neutral Extractables (625/8270) 14. GC/MS Semivolatile Unknown Scan mg/L 1115. Haloacetic Acids (552)ga Total Chlorine Res: pH __ 10116, Pesticides (SM18/6630)_e 1 /. Petroleum/Hydrocaron bears (310-13) ‘ ! -* i l, a itio 16. Purgeable Aromatics (DEF) i /. P estioides/PB 8 (ULF) *i

18. Other:______ ___ ____ ___ 18. Other:________ __ ___ _____

INORGANIC ANAI YS1S HEQUCS TED - 1g)* (circle tests) hey .. ‘ 11. Color oaMt 2. Turbidity X 20. Acidity 21. Alkalinity, as CaCO3 f f 39. Aluminum ------ ---------- — 59\Potassium 40. Antimony /60. ’Selenium ; 3.pH 22. Bromide 23. Bromate/Chlorate/Chlorite > 41. Arsenic 1 42.Barium ( 61. Silver ) f (i] 62. podium 4. Conductivity 5. Corrosivity (temp:...... °C) 24. Chloride \ 43 Beryllium 63. Thallium . 6. BOD (5 day) 25. Cyanide ■44, Boron 64.jVanadium 7. Soluble BOD (5 day) 26. Fluoride 45.Cadmium -65/Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 28. Nitrogen, Ammonia as N 46. Calcium, as CaCOs 47.alcium, Ca*2 ClP- 9. Chemical Oxygen Demand 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 9Chromium, Hexavalent 68. Semi-violatiles ' 3 Total Organic Halides 31. Nitrogen, Total Kjeldahl as N iSO.^obalt 69. Pesticides/PCB’s .. . Solids, Percent (%) 14. Solids, Settleable ( ; 32. Oil an Grease 33. Phenol 34. Phosphorus Total as P 0 52.ron 151 .Copper

53.Leadbm 70. Disk Deliverables TCLR_ 71.TCLP-Metals 10. Solids, Total 17. Solids, Total Dissolved .37. Surfactants oo 36. Sulfates 1 56. Mercury 35. Phosphorus, Ortho as P । । 54 .Magnesium 55 Manganese 72. TCLP-Pesticides

18. Solids, Total Volatile . . , 19. Other Aee 38.UV254 1 5857 MolNickel ybdenumth 74.TCLP-Volatiles /&TOLP boor . iriFRMA Aad NYC-WTC_000026204