Chain of custody form, Sep 2001

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM estdiot WESTCHESTER COUNTY LABORATORIES AND RESEARCH . Nt.) 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): ■ C-752,(0102 -is? 202, LA.

1. Potable J 3. Non Potable Treated Bottle #s 1012-, 4 2/3*7

2.Nn Potable 4. Other___ Chain of Custody? _ yes _ _ no Time/Date Collected: 1/00 I Comments:

Collected By: . z Agency Code: PWS #:......... ............ Source ID: ___ Type Descriptor:___ Collected From: Bill to: Location’s/Individual’s Name _NLL Name/Company Street... ________________________ ______ Street.. .....__ ___ _ City/StZip _ laakkda__ A__ ( i City/StZip Identification of Source____ Phone#; Fax#: _

Collection Point..................... CA,CH, Bl? _ Check#: Amounts .............. BACTERIOLOGICAL ANALYSIS ORGANIC POTABLE ANALYSIS ORGANIC NONPOTABLE/SOLID ANALYSIS Lab#:__ ____ __________ Lab#: __ _ 24 (circle tests) C / /1/ 2/ (Vz (circle tests) 1. Heterotrophic Plate 1. Trihalomethanes (524) 1. Purgeable Halocarbons (624/8260) Count (hemodialysis & all others) .2. Volatile Halocarbons (524) 2. Purgeable Aromatics (624/8260) 2. Coliform P/A (public supplies) 3..olatile Aromatics (524) . 3. Acrolein & Acrylonitrile (624) 3. Coliform MPN (privwell, raw, stp) 4. Total Trihalomethane Potential (510) 4. Phthalates (625/8270) 4 Fecal Coliform (all samples) 5. Microextractables (504) ‘ i1 : dmpl’edicido (G/ ri;) Aicroscopic 6. Pesticides (507) i * Arochiol) (020) 6. Macroscopic

8. G ____ _ __ ( 7. Pesticides/PCB screen (508) 8 PCB as Decachlorobiphenyl (508A) Herbicides (515) -87.Methoprene(616)Cm , Herbicides (EPA1978/8151) t 9. Pesticides (SM18/6630) 10._Pesticides (525) 10. Petroleum Hydrocarbon Scan (310-13) Refrigerated?____ yes____ no

Chlorinated:? ____ yes____ no 11. Carbamate Pesticides (531) 12. Glyphosate (547) 11 Glycols 1 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 15. Haloacetic Acids (552) 15. Purgeable Halocarbons (DEF) Total Chlorine Res: _ _ ______mg/L 16. Pesticides (SM18/6630) 16. Purgeable Aromatics (DEF) pH _ 17. Petroleum/Hydrocarbon Scan (310-13) 17. Pesticides/PCB’s (DEF) 118. Other m 18. Other:

INORGANIC ANALYSIS REQUESTED - Lab#: (circle tests) " /X2 1. Color B . 2. Turbidity 20. Acidity '21. Alkalinity, as CaCOs • 39. Aluminum ——■ ; 40. Antimony / 59. Potassium j .60. Selenium 3.pH 22. Bromide npgad I 41. Arsenic . tt It io. 4. Conductivity 23. Bromale/ci iloraierl iior ne 24. Chloride 42 Barium _ A \ 43. Beryllium i | 62. Sodium 63 J Thallium 5. Corrosivity (temp:_... _°C) 6. BOD (5 day) 25. Cyanide 44. Boron | 64, Vanadium 7. Soluble BOD (5 day) 26. Fluoride .'45. Cadmium U 65 Zinc 8. Carbonaceous BOD (5 day) 27. Hardness, Total as CaCOs 28. Nitrogen, Ammonia as N 46. Calcium, as CaCOa 47,Calcium, Ca+2 eLP 9. Chemical Oxygen Demand 66. Metals/CN 10. Dissolved Oxyaen 29. Nitrogen, Nitrate as N • 48.'Chromium, Total 67. Volatiles 30. Nitrogen, Nitrite as N 49 Chromium, Hexavalent 11. Total Organic Carbon 68. Semi-violatiles 31. Nitrogen, Tola! Kjeldahl as N 50.Cobalt \ Total Organic Halides 69. Pesticides/PCB’s

33. Phenol ---) 51, J. Solids, Percent (%) 32. Oil an Grease Copper 70. Disk Deliverables 52. Iron 14.Golids, Settleable TCLP ‘ hae 16. Solids, Total 34. Phosphorus Total as P 35. Phosphorus, Ortho as P 53.lead 54 Magnesium 71 TCLP-Metals / I < I I' Por* lo . 37. Surfactants 1 56. Mercury A 55 Manganese

19.18. OtSolhiedrs, Totwa 36. Sulfates al Volam 17. Solids, Total Dissolved tile “ 38.UV254 57 Molybdenum : I Cl l' to ic ■ / 1C !■ Volaiiie 58. Nickel sm 2) i;;ii’HN-v

NYC-WTC_000026206