Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM \estl sto WESTCHESTER COUNTY LABORATORIES AND RESEARCH ' - 20Urll 2 Dana Road, Valhalla, New York 10595 (914) 593-5575 NYS-ELAP No. 10108 Time/Date Set: Form A-70 (rev. 1/96)

Sample Type (circle one): inioimnkimd . 1. Potablej 3. Non Potable Treated Bottle #‘s:____ _ A GooFA 2. Non Potable 4. Other___ __________________ Chain of Custody?__ y. . 1)

Time/Date Collected:_ ________ __ __ Comments:____ ____ Collected By:__ _ _____________ Agency Code: PWS ______ _____ _ _ Source ID ........Type Descriptor: _

Collected From: Bill to: a Location’s/Individual’s Name Ki t / < _ DP Name/Company....... Street_ ....... — 1UU-St Street_____________ City/StZip ....... - City/St/Zip Identification of Source Phone#: Fax#:

Collection Point CA,CH, BI? Check#: Amounts____

BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:____ ____ __ _______________ Lab#:____ (circie tests) (circle tests) .7 L- 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) C 2> Volatile Halocarbons (524) . i . are Aiomati Mtofan 2. Coliform P/A (public supplies) 3. Coliform MPN (priv well, raw, stp) " Fecal Coliform (all samples) t Voliilu Ari " p 4. Total Trihalomethane Potential (510) " ,5. Microextractables (504),1 —4, Phthalates (625/8270) - . * I s A rylonitie (4) s Microscopic —-6. Pesticides (507) 5. Organochlorine Pesticides (608/8081) 6} PCB’s (Arochlors) (608/8081) * 6. Macroscopic (.7. Pesticides/PCB screen (508)-= 8. .PCB as Decachlorobiphenyl (508A) 7. Methoprene (616) 8. Herbicides (EPA1978/8151) 5

er: 9: Herbicides (515) 9. Pesticides (SMI8/6630) . ( 10. Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) - Refrigerated?.... .. yes___ no

Chlorinated:? ......._ yes .... ....no 11. Carbamate Pesticides (531) 12. Glyphosate (547) 11. Glycols —01 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 (SM1 8/6630) 16. Purgeable Aromatics (DEF) pH . 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 1118. Other 18. Other:........ ... .........

INORGANIC ANALYSIS REQUFSTE0 ■ I an (circle tests) 1. Color aaazenddomm 2. Turbidity i 20. Acidity 21. Alkalinity, as CaCOs i 39. Aluminum 40. Antimony" 59 Potassium! 60i Selenium ; 1 , _ - .J

3, pH 22. Bromide 23. Bromate/Chlorate/Chlorite i 41. Arsenic i 42. Barium o’Silver • 61. i 62. Sodium j? (’) ? . ■ 4. Conductivity 5. Corrosivity (temp:______ U) 24. Chloride 43/Beryllium ; 63. Thallium j 25. Cyanide '•44. Boron : 64, Vanadium1 6. BOD (5 day) 26. Fluoride . 45. Cadmium 165! Zinc : 7. Soluble BOD (5 day) 8. Carbonaceous BOD (5 day) 9. Chemical Oxygen Demand 27. Hardness, Total as CaCOs 28. Nitrogen, Ammonia as N 46. Calcium, as CaCOa 47. Calcium, Ca " [CLP= 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 Total Organic Halides 31. Nitrogen, Total Kjeldahl as N 4 50‘.Cobalt ig Feotori a/pon 32. Oil an Grease | 51 (Copper .j. Solids, Percent (%) A izi r ■- -li-'- -r.it >l- ■: 14. Solids, Settleable A. ,!■■■ . $-1- 34.33. Phenol Phosphorusedpann Total as P l 52.Iron 53 Lead—• TCLP 10, Solids. Total __ : , Pho. plrn. U t > ■■ I ! ..,) 1 7 1 161 PM-m.iis

36. Surfactants 18.19. SolOtherids, Total Volatile Day" 37. 17. Solids, Total Dissolved Sulfates mmlna --- 56. Mercury 55 Manganese TO !P "ei • 73. TCLP-Herbicides

38.UV254n 57Molyodenum 58/Nickel .1 1C "Vn, o ■ /5 H । Ptw

NYC-WTC_000026205